TO: ALL MEMBERS, ELECTED MEMBERS AND OFFICER REPRESENTATIVES OF THE PERFORMANCE AND AUDIT COMMITTEE OF DUNDEE CITY HEALTH AND SOCIAL CARE INTEGRATION JOINT BOARD (See Distribution List attached)

Dear Sir or Madam

PERFORMANCE AND AUDIT COMMITTEE

I would like to invite you to attend a meeting of the above Committee which is to be held remotely on Wednesday, 3rd February, 2021 at 10.00am.

Members of the Press or Public wishing to join the meeting should contact Committee Services on telephone (01382) 434228 or by email at committee.services@dundeecity.gov.uk by no later than 12 noon on Monday, 1st February, 2021.

Apologies for absence should be intimated to Willie Waddell, Committee Services Officer, on telephone 01382 434228 or by e-mail willie.waddell@dundeecity.gov.uk.

Yours faithfully

VICKY IRONS Chief Officer

AGENDA

1 APOLOGIES FOR ABSENCE

2 DECLARATION OF INTEREST

Members are reminded that, in terms of the Integration Joint Board’s Code of Conduct, it is their responsibility to make decisions about whether to declare an interest in any item on this Agenda and whether to take part in any discussions or voting. 3 MINUTE OF PREVIOUS MEETING - Page 1

The minute of previous meeting of the Committee held on 24th November, 2020 is attached for approval.

4 DUNDEE HEALTH AND SOCIAL CARE PARTNERSHIP PERFORMANCE REPORT – 2020/2021 QUARTER 2 SUMMARY - Page 5

(Report No PAC1-2021 by the Chief Officer, copy attached).

5 HEALTH AND CARE EXPERIENCE SURVEY 2019/2020 ANALYSIS - Page 15

(Report No PAC2-2021 by the Chief Officer, copy attached).

6 GOVERNANCE ACTION PLAN PROGRESS REPORT - Page 25

(Report No PAC3-2021 by the Chief Finance Officer, copy attached).

7 DUNDEE INTEGRATION JOINT BOARD INTERNAL AUDIT PLAN PROGRESS REPORT - Page 65

(Report No PAC4-2021 by the Chief Finance Officer, copy attached).

8 INTERNAL AUDIT REVIEW – FINANCE - Page 71

(Report No PAC5-2021 by the Chief Finance Officer, copy attached).

9 DUNDEE HEALTH AND SOCIAL CARE PARTNERSHIP CLINICAL CARE AND PROFESSIONAL GOVERNANCE ASSURANCE REPORT - Page 89

(Report No PAC6-2021 by the Clinical Director, copy attached).

10 QUARTERLY COMPLAINTS PERFORMANCE – 2ND QUARTER 2020/2021 - Page 111

(Report No PAC7-2021 by the Chief Social Work Officer, copy attached).

11 DUNDEE HEALTH AND SOCIAL CARE PARTNERSHIP STRATEGIC RISK REGISTER – UPDATE - Page 117

(Report No PAC8-2021 by the Chief Finance Officer, copy attached).

12 ATTENDANCE LIST - Page 125

(A copy of the Attendance Return (PAC9-2021) for meetings of the Performance and Audit Committee held over 2020 is attached for information and record purposes).

13 PROGRAMME OF MEETINGS - PERFORMANCE AND AUDIT COMMITTEE – 2021

The Committee is asked to note that the programme of meetings for the Performance and Audit Committee over the remainder of 2021 will be as follows:-

Wednesday 24th March 2021 - 10.00am Wednesday 26th May 2021 - 10.00am Wednesday 29th September 2021 - 10.00am Wednesday 24th November 2021 - 10.00am

All meetings will be held remotely unless otherwise advised by the Clerk.

14 DATE OF NEXT MEETING

The next meeting of the Committee will be held remotely on Wednesday, 24th March, 2021 at 10.00 am (unless otherwise advised by the Chief Officer). PERFORMANCE AND AUDIT COMMITTEE PUBLIC DISTRIBUTION LIST

(a) DISTRIBUTION – PERFORMANCE AND AUDIT COMMITTEE

(\* - DENOTES VOTING MEMBER)

| Role | Recipient | |----------------------------------------------------------------------|----------------------------------| | NHS Non Executive Member (Chair) | Trudy McLeay * | | Elected Member | Councillor Roisin Smith * | | Elected Member | Bailie Helen Wright * | | NHS Non Executive Member | Donald McPherson\* | | Chief Officer | Vicky Irons | | Chief Finance Officer | Dave Berry | | Registered medical practitioner employed by the Health Board and not | James Cotton | | providing primary medical services | | | Chief Social Work Officer | Diane McCulloch | | Chief Internal Auditor | Tony Gaskin | | Staff Partnership Representative | Raymond Marshall | | Person providing unpaid care in the area of the local authority | Martyn Sloan |

(b) DISTRIBUTION – FOR INFORMATION ONLY

| Organisation | Recipient | |----------------------------------------------------------------------|------------------------------------| | Dundee City Council (Chief Executive) | Greg Colgan | | Elected Member – Proxy | Depute Lord Provost Bill Campbell | | Elected Member – Proxy | Councillor Lynne Short | | Elected Member – Proxy | Councillor Margaret Richardson | | Dundee City Council (Executive Director of Corporate Services) | Robert Emmott | | Dundee City Council (Head of Democratic and Legal Services) | Roger Mennie | | NHS Tayside (Chief Executive) | Grant Archibald | | NHS Non Executive Member – Proxy | Norman Pratt | | NHS Tayside (Director of Finance) | Stuart Lyall | | Dundee City Council (Members’ Support) | Jayne McConnachie | | Dundee City Council (Members’ Support) | Dawn Clarke | | Dundee City Council (Members’ Support) | Fiona Barty | | Dundee City Council (Members’ Support) | Sharron Wright | | Dundee City Council (Communications rep) | Steven Bell | | Dundee Health and Social Care Partnership | Kathryn Sharp | | NHS Tayside (Communications rep) | Jane Duncan | | NHS Fife (Internal Audit) (Principal Auditor) | Judith Triebs | | NHS (PA to Tony Gaskin) | Carolyn Martin | | Audit Scotland (Audit Manager) | Anne Marie Machan | | Dundee City Council (Secretary to Dave Berry) | Pauline Harris | | NHS Tayside (PA to James Cotton) | Jodi Lyon | At a MEETING of the PERFORMANCE AND AUDIT COMMITTEE OF THE DUNDEE CITY HEALTH AND SOCIAL CARE INTEGRATION JOINT BOARD held remotely on 24th November, 2020.

Present:-

| Members | Role | |--------------------------|-----------------------------------------------------------| | Trudy McLEAY (Chairperson) | Nominated by Health Board (Non-Executive Member) | | Lynne SHORT | Nominated by Dundee City Council (Elected Member) | | Helen WRIGHT | Nominated by Dundee City Council (Elected Member) | | Donald MCPHERSON | Nominated by Health Board (Non-Executive Member) | | Dave BERRY | Chief Finance Officer | | Tony GASKIN | Chief Internal Auditor | | Vicky IRONS | Chief Officer | | Diane McCULLOCH | Chief Social Work Officer | | Martyn SLOAN | Carer Representative |

Non-members in attendance at the request of the Chief Finance Officer:-

| Members | Role | |--------------------------|-----------------------------------------------------------| | Kevin GRUBB | Health and Social Care Partnership | | Christine JONES | Health and Social Care Partnership | | Matthew KENDALL | Health and Social Care Partnership | | Anne Marie MACHAN | Audit Scotland | | Fiona MITCHELL-KNIGHT | Audit Scotland | | Amber OGILVIE | Audit Scotland | | Kathryn SHARP | Health and Social Care Partnership | | Sheila WEIR | Health and Social Care Partnership |

Trudy McLeay, Chairperson, in the Chair.

I APOLOGIES FOR ABSENCE

Apologies for absence were submitted on behalf of:-

| Members | Role | |--------------------------|-----------------------------------------------------------| | Roisin SMITH | Nominated by Dundee City Council (Elected Member) | | James COTTON | Registered medical practitioner employed by Health Board and not providing primary medical services | | Raymond MARSHALL | Staff Partnership Representative |

II DECLARATION OF INTEREST

No declarations of interest were made.

III PERFORMANCE AND AUDIT COMMITTEE MEMBERSHIP AND CHAIRPERSON

Reference was made to Article IV of the minute of meeting of the Integration Joint Board held on 27th October, 2020, wherein the membership of the Performance and Audit Committee was agreed and appointment was made to the position of Chairperson of the Committee.

The Committee noted that the membership of the Performance and Audit Committee was agreed as follows:- Councillor Roisin Smith, Bailie Helen Wright, Trudy McLeay, Donald McPherson, Diane McCulloch, James Cotton, Raymond Marshall and Martyn Sloan, and that Trudy McLeay was appointed to the position of Chairperson. IV MINUTE OF PREVIOUS MEETING

The minute of meeting of the Committee held on 22nd September, 2020 was submitted and approved.

V AUDIT SCOTLAND ANNUAL REPORT AND INTEGRATION JOINT BOARD ANNUAL ACCOUNTS 2019/2020

There was submitted Report No PAC36-2020 by the Chief Finance Officer presenting the Integration Joint Board’s (IJB) Draft Audited Annual Statement of Accounts for the year to 31st March, 2020 for approval, to note the draft external auditor’s report in relation to these accounts and approve the response to this report.

The Performance and Audit Committee:

(i) Noted the contents of the Audit Scotland cover letter (attached as Appendix 1) and the draft external auditor’s report (attached as Appendix 2) including the completed action plan outlined on pages 28-33 of the report, and in particular that Audit Scotland have indicated they will issue an unqualified audit opinion on the IJB’s 2019/2020 Annual Accounts;

(ii) Endorsed the report as the IJB’s formal response to the external auditor’s report;

(iii) Instructed the Chief Finance Officer to provide an update on progress of the action plan noted in Appendix 1 of the external auditor’s report by January 2021;

(iv) Approved the Audited Annual Accounts (attached as Appendix 3) for signature and instructed the Chief Finance Officer to return these to the external auditor;

(v) Instructed the Chief Finance Officer to arrange for the Annual Accounts to be published on the Dundee Health and Social Care Partnership website by no later than Monday 30th November, 2020.

VI MEASURING PERFORMANCE UNDER INTEGRATION 2020/2021

There was submitted Report No PAC32-2020 by the Chief Finance Officer seeking approval of an interim approach to assessing and reporting performance against Measuring Performance under Integration indicators set by the Ministerial Strategic Group for Health and Community Care (MSG) during 2020/2021.

The Performance and Audit Committee:

(i) Noted the content of the report, including the need to agree a formal position in relation to the reporting of performance against Measuring Performance under Integration indicators for 2020/2021 as noted in section 4.2.3 of the report; and

(ii) Agreed the proposal that Measuring Performance under Integration targets were not set for 2020/2021 but that data continued to be integrated into the Quarterly Performance Reports submitted to PAC as noted in section 4.2.6 of the report.

VII CLINICAL, CARE AND PROFESSIONAL GOVERNANCE (CCPG) – PERIOD MARCH 2020 – JULY 2020

The Performance and Audit Committee noted that this report had been withdrawn. A verbal update was given by Matthew Kendall, Allied Health Professions Lead and the Committee noted the following key points: • Risk Management – significant work was required in this area and the position had now improved however, additional work was required to bring the NHS and Council systems together; • Governance Arrangements – education and peer support mechanism in place; • Adverse Events – there was a reduction of adverse events with harm. Ongoing training was in place for staff. Noted a change in demographic in the patients in Psychiatry of Old Age and Medicine for the Elderly; • Falls – work had taken place with the Scottish Ambulance Service to develop a dataset and additional funding had been received to continue work with the Service; • Complaints – a new report was being developed to present the number of complaints received monthly over time.

The Performance and Audit Committee agreed that a written report would be brought to the next Committee for information.

VIII GOVERNANCE ACTION PLAN PROGRESS REPORT

There was submitted Report No PAC34-2020 by the Chief Finance Officer providing the Performance and Audit Committee with an update on the progress of the actions set out in the Governance Action Plan.

The Performance and Audit Committee noted the progress made in relation to the actions set out in the Governance Action Plan as outlined in Appendix 1 of the report.

IX DUNDEE INTEGRATION JOINT BOARD INTERNAL AUDIT PLAN PROGRESS REPORT

There was submitted Report No PAC35-2020 by the Chief Finance Officer providing the Performance and Audit Committee with a progress update in relation to the current Internal Audit Plan.

X MEETING OF PERFORMANCE AND AUDIT COMMITTEE 2020 - ATTENDANCES

There was submitted a copy of the Attendance Return PAC38-2020 for meetings of the Performance and Audit Committee held over 2020.

The Performance and Audit Committee noted the position as outlined.

XI DATE OF NEXT MEETING

To be advised.

Trudy McLEAY, Chairperson. 1.0 PURPOSE OF REPORT

1.1 The purpose of this report is to update the Performance and Audit Committee on 2020-21 Quarter 2 performance against the National Health and Wellbeing Indicators and ‘Measuring Performance Under Integration’ indicators.

2.0 RECOMMENDATIONS

It is recommended that the Performance & Audit Committee (PAC):

2.1 Note the content of this summary report.

2.2 Note the performance of Dundee Health and Social Care Partnership, at both Dundee and Local Community Planning Partnership (LCPP) levels, against the National Health and Wellbeing Indicators as summarised in Appendix 1.

2.3 Note the performance of Dundee Health and Social Care Partnership against the ‘Measuring Performance Under Integration’ indicators as summarised in Appendix 1 (table 2).

3.0 FINANCIAL IMPLICATIONS

3.1 None.

4.0 BACKGROUND

4.1 In February 2019 the Performance and Audit Committee approved a revised approach to quarterly performance reporting; with summary reports being provided in Quarters 1 and 3 of each financial year and full reports in Quarters 2 and 4 (Article V of the minute of the meeting of the Dundee PAC held on 12 February 2019 refers). A full report was provided in Q1 to allow the Performance and Audit Committee to understand and scrutinise early information about the impact of the COVID-19 pandemic on key areas of performance. For this reason this Q2 report is a summary report and the original reporting schedule will resume from Q3.

4.2 The Quarter 2 Performance Report analyses performance against National Health and Wellbeing Indicators 1-23 and Measuring Performance Under Integration (MPUI) indicators. 5 of the 23 National Health and Wellbeing Indicators are monitored quarterly (emergency admissions, emergency bed days, readmissions, falls admissions and delayed discharge bed days lost) Appendix 1 provides a summary of performance. Data is provided both at Dundee and Local Community Planning Partnership (LCPP) level (where available). Data is currently not available for eight out of the 13 National Indicators which are not reported using The Health and Social Care Experience Survey (see section 4.3). The Scottish Government and Public Health Scotland are working on the development of definitions and datasets to calculate these indicators nationally. 4.3 The National Health and Wellbeing Indicators 1-9 are reported from The Health and Social Care Experience Survey administered by the Scottish Government which is conducted biennially. Full details have been provided in PAC2-2021 that is also on this agenda. A summary of the published results from the 2019-20 survey is provided in Appendix 1 (table 1). The Scottish Government changed the methodology used to filter responses to reflect people who receive services from the Partnership and therefore it is not possible to longitudinally compare results for National Indicators 1-7 and 9.

4.4 Appendix 1 also summarises performance against indicators in the Measuring Performance Under Integration (MPUI) suite of indicators for four out of six high level service delivery areas – emergency admissions, emergency bed days, accident and emergency and delayed discharges. Detail is provided in Appendix 2. We are currently unable to provide analysis for balance of care and end of life as data is not provided by Public Health Scotland for these service areas. In November 2020 the Performance and Audit Committee agreed that targets are not set for 2020-21 for these indicators but that data continues to be integrated into the quarterly performance reports submitted to PAC (Article VI of the minute of the Dundee Performance and Audit Committee held on 24 November 2020 refers).

4.5 This report should be assessed with regard to the demographic and socio economic context of Dundee; high rates of deprivation, an ageing population, frailty and age associated conditions being diagnosed earlier in life than in more affluent Partnerships and deprivation associated mental health illnesses and substance misuse problems.

4.6 The impact of the COVID-19 pandemic on the health and social care needs of the population, how we deliver supports and services, on health inequalities and on the health and wellbeing of our workforce and of unpaid carers has been substantial and wide ranging. Information about the direct impact of the pandemic is shaping and influencing how services are provided. The priority given to reducing demand on unscheduled care temporarily shifted as Health and Social Care Partnerships adapted processes, procedures and pathways in order to prevent spread of the virus and to maximise hospital capacity to treat COVID-19 patients safely and effectively. This adds a level of complexity to the indicators monitored since 2015/16 to measure how Partnerships are performing towards ‘shifting the balance of care’. This report presents indicators for all admission reasons and non-COVID admission reasons separately where this is possible and relevant in order to allow scrutiny of performance towards the national indicators for people not diagnosed with COVID-19. All indicators where processes and pathways were affected by the pandemic should be treated with caution and viewed alongside whole system pathways and processes when scrutinising performance.

5.0 DATA SOURCES USED FOR MEASURING PERFORMANCE

5.1 National data is provided to all partnerships, by Public Health Scotland, to assist with monitoring against targets set under Measuring Performance under Integration arrangements. This data shows rolling monthly performance for emergency admissions, emergency admissions from accident and emergency, accident and emergency attendances, emergency bed days and delayed discharges. Previously Public Health Scotland were only able to provide data for all ages, however following feedback from Dundee and other Partnerships they have now provided data for people age 18+. (Please refer to Appendix 1, Table 2).

5.2 It was agreed at the PAC held on 19 July 2017 (Article VIII of the minute of the meeting refers) that local data, provided by the NHS Tayside Business Unit will be used to produce more timeous quarterly performance reports against the National Health and Wellbeing Indicators. NHS Tayside Business Unit has provided data for emergency admissions, emergency bed days, readmissions, delayed discharges and falls. From quarter 1 2020-21 the NHS Tayside Business Unit has been providing breakdowns of covid and non covid admission reasons for emergency admissions,

______________________________________________________________________

1 Rolling data is used so that quarterly data can be compared with financial years. This means that data for Quarter 2 shows the previous 12 months of data including the current quarter. Therefore, Quarter 2 data includes data from 1 October 2019 to 30 September 2020. emergency bed days, hospital admissions due to a fall and delayed discharges. (Please refer to Appendix 1, Tables 3 and 4).

5.3 Data provided by NHS Tayside differs from data provided by Public Health Scotland (PHS); the main differences being that NHS Tayside uses ‘board of treatment’ and PHS uses ‘board of residence’ and NHS Tayside uses an admissions based dataset whereas PHS uses a discharge based dataset (NHS Tayside records are more complete but less accurate as PHS data goes through a validation process). As PHS data is discharge based, numbers for one quarter will have been updated the following quarter as records get submitted for those admitted one quarter and discharged a subsequent quarter. By the time PHS release their data, records are (in most cases) 99% complete. The data provided by NHS Tayside Business Unit is provisional and figures should be treated with caution.

6.0 QUARTER 2 PERFORMANCE 2020-21

6.1 Rolling data from October 2019 to September 2020 demonstrates that all indicators that make-up the Measuring Performance under Integration suite, with the exception of emergency admissions as a rate per 1000 of all A&E attendances, have improved between Q1 2020-21 and Q2 2020-21. Please refer to Table 2 in Appendix 1.

6.2 Tables 3 and 4 in Appendix 1 summarise performance against the National Health and Wellbeing Indicators at both Dundee and LCPP level using rolling local data from October 2019 to September 2020.

6.2.1 Between the baseline year (2015/16) and 2020/21 Quarter 2 there has been improved performance in: rate of bed days lost to delayed discharge for people aged 75+ (for both Standard and Complex delays) and emergency bed day rate for people aged 18+. In the same period there has been a deterioration in performance in: emergency admission rate for people aged 18+ (there was a small increase of 0.1% which amounted to 95 admission); readmissions rate for people of all ages; and the rate of hospital admissions as a result of a fall for people aged 65+. This is the same pattern of performance as reported in 2020-21 Quarter 1 (Article V of the minute of the Dundee Performance and Audit Committee held on 22 September 2020 refers) and there are therefore no exceptions to report to PAC.

6.2.2 Between the baseline year 2015/16 and 2020/21 Quarter 2 there was an improvement in the rate of bed days lost to complex delayed discharges for people aged 75+ across all Local Community Planning Partnerships (LCPPs) except Maryfield (6.4% increase). There was a 72.1% improvement in Dundee and the LCPP rates ranged from a 100% improvement in East End to a 6.4% deterioration in Maryfield.

6.2.3 Between the baseline year 2015/16 and 2020/21 Quarter 2 there was an improvement in the rate of bed days lost to standard delayed discharges for people aged 75+ across all LCPPs. There was a 49.0% improvement in Dundee and improvements ranged from 11.4% in The Ferry and 74% in Maryfield.

6.2.4 Emergency bed day rates since 2015/16 have decreased by 22.2% for Dundee, which is an improvement. Every LCPP showed an improvement in 2020/21 Quarter 2 compared with 2015/16 and improvements ranged from 14.1% in Strathmartine to 34.9% in East End. Improvements are even better when COVID admission reasons were excluded – 23.3% improvement in Dundee, ranging from 15.3% improvement in Strathmartine to 35.9% improvement in East End.

6.2.5 Emergency admission rates have increased by 0.1% for Dundee since 2015/1, which is a deterioration and there were increases in North East (1.2%), Strathmartine (3.4%), East End (4.5%) and Maryfield (5.8%). Performance ranged from an increase in Maryfield (+5.8%) to a decrease in The Ferry (-10.6%).

When excluding Covid admission reasons performance is better and shows a 1.6% decrease since 2015/16, which is an improvement, however there were increases in East End (2.3%) and Maryfield (4.2%) which is a deterioration. Performance ranged from an increase in Maryfield (+4.2%) to a decrease in The Ferry (-11.8%). 6.2.6 The rate of readmissions in Dundee has increased by 25% since 2015/16. The rate increased (deteriorated) in 6 LCPPs (West End 48% increase, Lochee 42% increase, Coldside 30% increase, Strathmartine 29% increase, East End 24% increase and Maryfield 23% increase). The rate decreased (improved) in 2 LCPP areas (North East 14% decrease and The Ferry 17% decrease).

6.2.7 The rate of hospital admissions as a result of a fall for people aged 65+ in Dundee has increased by 22.0% since 2015/16, which is a deterioration. The rate increased in all LCPP areas. The increases ranged from 4.7% in North East to 52.9% in The Ferry.

7.0 POLICY IMPLICATIONS

7.1 This report has been screened for any policy implications in respect of Equality Impact Assessment. There are no major issues.

8.0 RISK ASSESSMENT

| Risk 1 Description | The risk of not meeting targets against national indicators could affect; outcomes for individuals and their carers, spend associated with poor performance if the Partnership’s performance is not good. | |--------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------| | Risk Category | Financial, Governance, Political | | Inherent Risk Level| 15 – Extreme Risk (L=3 (possible), I=5 (extreme)) | | Mitigating Actions (including timescales and resources ) | - Continue to develop a reporting framework which identifies performance against national and local indicators.

- Continue to report data quarterly to the PAC to highlight areas of poor performance.
- Continue to support operational managers by providing in depth analysis regarding areas of poor performance, such as around readmissions to hospital and falls related hospital admissions.
- Continue to ensure that data informs operational practices and improvements and also that operational activities and priorities are used to interpret trends shown by the data. | | Residual Risk Level | 9 – High Risk (L=3(possible), I=3 (moderate)) | | Planned Risk Level | 6 – Moderate Risk (L=2(unlikely), I=3(moderate)) | | Approval recommendation | Given the moderate level of planned risk, this risk is deemed to be manageable. |

9.0 CONSULTATIONS

9.1 The Chief Officer, Head of Service, Health and Community Care and the Clerk were consulted in the preparation of this report.

10.0 BACKGROUND PAPERS

10.1 None.

### APPENDIX 1 – Performance Summary

#### Table 1 – National Health and Wellbeing Indicators 1-9

| Indicator | Scotland | Dundee | North Lanarkshire | Glasgow | North Ayrshire | Inverclyde | West Dunbartonshire | East Ayrshire | Western Isles | |---------------------------------------------------------------------------|----------|--------|-------------------|---------|----------------|------------|---------------------|---------------|--------------| | 1. Percentage of adults able to look after their health very well or quite well | 93% | 92% | (joint 2nd best) | 90% | 90% | 92% | 90% | 91% | 92% | 94% | | 2. Percentage of adults supported at home who agreed that they are supported to live as independently as possible | 81% | 79% | (2nd poorest) | 78% | 82% | 84% | 91% | 80% | 86% | 81% | | 3. Percentage of adults supported at home who agreed that they had a say in how their help, care, or support was provided | 75% | 73% | (3rd poorest) | 71% | 76% | 75% | 82% | 83% | 79% | 70% | | 4. Percentage of adults supported at home who agreed that their health and social care services seemed to be well co-ordinated | 74% | 72% | (2nd poorest) | 70% | 75% | 76% | 82% | 77% | 84% | 80% | | 5. Percentage of adults receiving any care or support who rate it as excellent or good | 80% | 75% | (poorest) | 78% | 79% | 77% | 85% | 83% | 80% | 86% | | 6. Percentage of people with positive experience of care at their GP practice | 79% | 79% | (4th best) | 68% | 83% | 73% | 78% | 81% | 70% | 87% | | 7. Percentage of adults supported at home who agree that their services and support had an impact on improving or maintaining their quality of life | 80% | 77% | (2nd poorest) | 76% | 79% | 79% | 83% | 82% | 87% | 86% | | 8. Percentage of carers who feel supported to continue in their caring role | 34% | 35% | (3rd poorest) | 33% | 36% | 31% | 39% | 37% | 36% | 39% | | 9. Percentage of adults supported at home who agreed they felt safe | 83% | 82% | (joint 3rd poorest) | 80% | 82% | 85% | 90% | 79% | 89% | 86% |

Source: Scottish Government, Health and Care Experience Survey 2019/20

**Key Points**

1. Best performing Family Group is highlighted in red and poorest is highlighted in red.
2. Dundee’s performance was poorer than the Scottish average in 7 out of the 9 indicators, the same for one indicator and better for one indicator.
3. The methodology was changed by Scottish Government on how the responses included in these results are filtered, therefore it is not accurate to compare longitudinally. This is because the question which allows the Scottish Government to ascertain which respondents receive care / support from the Health and Social Care Partnerships was changed and the interpretation of these questions is subjective and varies per respondent. Table 2: Measuring Performance under Integration Summary

| Integration Indicator (Annual 18+) | 15-16 Baseline | 20-21 Q1 Actual Data | 20-21 Q2 Actual Data | Actual % Difference from 15-16 Baseline | Direction of travel from Q1 to Q2 | |-----------------------------------|----------------|----------------------|----------------------|----------------------------------------|----------------------------------| | Emergency Admission Rate per 100,000 Dundee Population | 11,643 | 11,651 | 11,535 | ↑0.07 | ↓0.92 | Better | | Emergency Admission Numbers | 14,127 | 14,203 | 14,062 | ↑0.54 | ↓0.46 | Better | | Emergency Admissions Numbers from A&E | 6,483 | 7,160 | 7,136 | ↑10.44 | ↑10.12 | Better | | Emergency Admissions as a Rate per 1,000 of all Accident & Emergency Attendances | 277 | 322 | 335 | ↑16.44 | ↑21.08 | Worse | | Emergency Bed Day Rate for Acute Specialties per 100,000 Dundee Population | 100,284 | 76,190 | 73,042 | ↓24.02 | ↓27.17 | Better | | Emergency Bed Days Numbers for Acute Specialties | 121,683 | 92,881 | 89,043 | ↓23.67 | ↓26.82 | Better | | Emergency Bed Days Numbers for Mental Health Specialties | 44,552 | 32,630 | 32,195 | ↓26.76 | ↓27.74 | Better | | Accident & Emergency Attendances | 23,437 | 22,230 | 21,315 | ↓5.15 | ↓9.04 | Better | | Number of Bed Days Lost to Delayed Discharges per 1,000 Population (All Reasons) | 124 | 68 | 64 | ↓45.50 | ↓48.51 | Better | | Number of Bed Days Lost to Delayed Discharges (All Reasons) | 15,050 | 9,861 | 7,785 | ↓34.48 | ↓48.27 | Better | | Number of Bed Days Lost to Delayed Discharges (Code 9) | 6,668 | 3,707 | 3,422 | ↓44.41 | ↓48.68 | Better |

Source ISD: ISD MSG Indicators

Key:

- Improved/Better than previous quarter
- Declined/Worse than previous quarter

Key Points:

Published MSG data has been used to measure performance therefore there may be a discrepancy when comparing with the local performance data. Note late submissions of data may result in % differences reported varying from one quarter to another. Table 3: Performance in Dundee’s LCPPs - % change in Q2 2020-21 against baseline year 2015/16

| National Indicator | Dundee | Lochee | East End | Coldside | North East | Strathmartine | Maryfield | West End | The Ferry | |--------------------|--------|--------|----------|----------|------------|---------------|-----------|----------|-----------| | Emer Admissions rate per 100,000 18+ (Covid and Non Covid) | +0.1% | -0.7% | +4.5% | -0.4% | +1.2% | +3.4% | +5.8% | -0.3% | -10.6% | | Emer Admissions rate per 100,000 18+ (Non Covid Only) | -1.6% | -2.0% | +2.3% | -2.1% | -0.9% | +1.7% | +4.2% | -2.3% | -11.8% | | Emer Bed Days rate per 100,000 18+ (Covid and Non Covid) | -22.2% | -23.3% | -34.9% | -20.2% | -19.8% | -14.1% | -17.6% | -21.6% | -21.7% | | Emer Bed Days rate per 100,000 18+ (Non Covid Only) | -23.3% | -24.2% | -35.9% | -21.3% | -20.8% | -15.3% | -18.8% | -23.0% | -22.9% | | Readmissions rate per 1,000 Admissions All | +25% | +42% | +24% | +30% | -14% | +29% | +23% | +48% | +17% | | Hospital admissions due to falls rate per 1,000 65+ | +22% | +9.3% | +28.8% | +11.5% | +4.7% | +5.7% | +23.2% | +32.8% | +52.9% | | Delayed Discharge Bed Days Lost rate per 1,000 75+ (Standard) | -49.0% | -57.7% | -70.7% | -35.9% | -70.4% | -51.1% | -74.0% | -43.0% | -11.4% | | Delayed Discharge Bed Days Lost rate per 1,000 75+ (Code 9) | -72.1% | -8.9% | -100.0% | -74.0% | -75.3% | -92.2% | +6.4% | -62.4% | -57.5% | Table 4: Performance in Dundee’s LCPPs - LCPP Performance in Q2 2020-21 compared to Dundee

| National Indicator | Dundee | Lochee | East End | Coldside | North East | Strathmartine | Maryfield | West End | The Ferry | |--------------------|--------|--------|----------|----------|------------|---------------|-----------|----------|-----------| | Emer Admissions rate per 100,000 18+ (Covid and Non Covid) | 11,949 | 13,669 | 16,534 | 13,654 | 11,777 | 13,529 | 10,487 | 7,974 | 9,859 | | Emer Admissions rate per 100,000 18+ (Non Covid Only) | 11,748 | 13,488 | 16,190 | 13,426 | 11,530 | 13,320 | 10,326 | 7,815 | 9,721 | | Emer Bed days rate per 100,000 18+ (Covid and Non Covid) | 103,474 | 124,419 | 118,609 | 130,080 | 90,316 | 106,467 | 87,911 | 76,916 | 98,908 | | Emer Bed days rate per 100,000 18+ (Non Covid Only) | 101,970 | 122,875 | 116,838 | 128,219 | 89,204 | 104,888 | 86,618 | 75,570 | 97,380 | | Readmissions rate per 1,000 Admissions All\* | 140 | 147 | 154 | 149 | 95 | 150 | 150 | 153 | 114 | | Hospital admissions due to falls rate per 1,000 65+ | 30.4 | 29.1 | 35.3 | 33.3 | 21.5 | 26.6 | 28.6 | 36.6 | 31.0 | | Delayed Discharge bed days lost rate per 1,000 75+ (standard) | 268 | 257 | 191 | 355 | 140 | 240 | 155 | 388 | 278 | | Delayed Discharge bed days lost rate per 1,000 75+ (Code 9) | 82 | 150 | 0 | 115 | 188 | 32 | 172 | 81 | 18 |

Source: NHS Tayside data

\*covid admission reasons not available

Key:

- Improved/Better
- Stayed the same
- Declined/Worse 1.0 PURPOSE OF REPORT

1.1 The purpose of this report is to update the Performance and Audit Committee on the responses from the 2019-20 Health and Care Experience Survey, which is used to provide measurement for National Health and Wellbeing Indicators 1 to 9.

2.0 RECOMMENDATIONS

It is recommended that the Performance & Audit Committee (PAC):

2.1 Note the changes to the methodology used to filter responses and report against the National Health and Wellbeing Indicators (section 5).

2.2 Note the performance of Dundee Health and Social Care Partnership against the Scottish average and 8 Local Government Benchmarking Framework (LGBF) family group partnerships (section 6 and appendix 1).

2.3 Note that the survey results will be further considered as part of the ongoing revision of the Partnership’s Strategic Needs Assessment and by the Operational Management Team with a view to identify any further actions required to supplement ongoing improvement activity (section 7).

3.0 FINANCIAL IMPLICATIONS

3.1 None.

4.0 BACKGROUND

4.1 The Scottish Health and Care Experience Survey is a postal survey which is sent to a random sample of people who are registered with a GP in Scotland. The survey has been administered every two years since 2009-10 and forms part of the Scottish Care Experience Excellence Programme, which is a suite of national surveys that aims to provide local and national information on the quality of health and care services from the perspective of the people who use them.

4.2 The survey results are used nationally to inform planning and monitor performance, to monitor the NHS Scotland Local Delivery Plan standards on accessing GP services and to report against 9 of the 23 National Health and Wellbeing Outcome indicators under the Public Bodies (Joint Working) (Scotland) Act 2014.

4.3 The survey results are used locally by GP practices and Health and Social Care Partnerships to understand people’s experiences, allow benchmarking with other area Partnership areas and to inform future service planning and improvement. 5.0 LONGITUDINAL ANALYSIS

5.1 Health and Social Care Partnerships are required under the Public Bodies (Joint working) (Scotland) Act 2014, and associated regulations and guidance, to monitor performance from the pre-integration 2015-16 position to the current position. It is not possible for this to be done for National Health and Wellbeing Outcome indicators 1 to 7 and indicator 9 because the survey is biennial and because the methodology was changed by the Scottish Government between the 2017-18 and 2019-20 surveys. The Scottish Government has advised that comparing the results of the 2017-18 and 2019-20 surveys is not accurate and should not be undertaken as part of any further analysis of survey data.

5.2 In order to only report the responses of people who receive services from the Health and Social Care Partnerships, responses are filtered. The way in which these responses were filtered differed in 2017-18 and 2019-20, making the data incomparable.

5.3 The responses from the section about carers do not require to be filtered, therefore National Health and Wellbeing Outcome indicator 8, which asks if a carer feels supported to continue in their caring role, can be analysed longitudinally.

6.0 BENCHMARKING ANALYSIS

6.1 Dundee performed in the top 4 out of the 8 Local Government Benchmarking Framework (LGBF) family group partnerships for 3 out of the 9 indicators:

- Percentage of adults able to look after their health very well or quite well;
- Percentage of adults supported at home who agree that they are supported to live as independently as possible; and,
- Percentage of people with positive experience of the care provided by their GP practice

6.2 Dundee performed the same as or better than the Scottish average for 2 out of the 9 indicators.

- Percentage of people with positive experience of the care provided by their GP practice; and,
- Percentage of carers who feel supported to continue in their caring role.

6.3 Dundee therefore performed poorly when benchmarked against comparable Partnerships (LGBF family group) and / or the Scottish average in all indicators other than indicator 6 – percentage of people with positive experiences of care provided by their GP practice.

7.0 NEXT STEPS

7.1 The findings of the 2019-20 Health and Care Experience Survey will be considered and triangulated with other sources of information as part of the ongoing review of the Partnership’s Strategic Needs Assessment and of the Strategic and Commissioning Plan 2019-2022 (Article VI of the minute of the meeting of Dundee Integration Joint Board held on 15 December 2020 refers). However, the inability to utilise longitudinal analysis for the majority of indicators is a significant limitation on their use in this context.

7.2 The Operational Management Team will consider the findings of the survey, with a particular focus on indicators 3 to 5, indicator 7 and indicator 9 that focus on the co-ordination, quality and impact of care. It should be noted that poor perceptions of quality of care (indicator 5) should be considered alongside National Health and Wellbeing Outcome indicator 17 (proportion of care services graded ‘good’ (4) or better in Care Inspectorate inspections); in 2019-20 Dundee achieved 80% against a Scottish average of 82% representing a 6% decline from the previous year (2018-19) and a 8% decline from the pre-integration position (2015-16). Whilst there are a range of actions already being implemented to improve local arrangements for the personalisation, co-ordination and delivery of care, the Operational Management Team will consider what further actions may be required to address poor performance identified through the survey. 7.3 Dundee Carers Partnership is currently reviewing the statutory carers strategy for the city (Article VII of the minutes of the Dundee Integration Joint Board held on 25 August 2020 refers). The Carers Partnership will consider the findings of the survey in relation to outcome 8 and measures required to address the continued decline in the percentage of carers who feel supported to continue in their caring role.

7.0 POLICY IMPLICATIONS

7.1 This report has been screened for any policy implications in respect of Equality Impact Assessment. There are no major issues.

8.0 RISK ASSESSMENT

8.1 This report has not been subject to a risk assessment as it does not require any policy or financial decisions at this time.

9.0 CONSULTATIONS

9.1 The Chief Officer, Head of Service, Health and Community Care and the Clerk were consulted in the preparation of this report.

10.0 BACKGROUND PAPERS

10.1 None.

DATE: 21 January 2021

Dave Berry Chief Finance Officer

Lynsey Webster Senior Officer, Strategy and Performance

Kathryn Sharp Service Manager, Strategy and Performance APPENDIX 1

National Indicators 1-9 Family Group Analysis

National Indicator 1: Percentage of adults able to look after their health very well or quite well (Scotland)

- All family group partnerships except Western Isles performed worse than the Scottish average.
- Dundee performed 2nd best in the family group, however worse than the Scottish average.

National Indicator 2: Percentage of adults supported at home who agree that they are supported to live as independently as possible (Scotland)

- All family group partnerships except Western Isles performed worse than the Scottish average.

- Dundee performed 3rd best in the family group, however worse than the Scottish average. National Indicator 3: Percentage of adults supported at home who agree that they had a say in how their help, care or support was provided. (Scotland)

- 5 of the 8 family group partnerships performed the same or better than the Scottish average.

- Dundee’s performance was the 3rd poorest in the family group and poorer than the Scottish average.

National Indicator 4: Percentage of adults supported at home who agree that their health and care services seemed to be well co-ordinated (Scotland)

- 6 of the 8 family group partnerships performed better than the Scottish average.

- Dundee’s performance was the 2nd poorest in the family group and poorer than the Scottish average. National Indicator 5: Percentage of adults receiving any care or support who rate it as excellent or good (Scotland)

- 4 of the 8 (50%) family group partnerships performed the same as or better than the Scottish average.

- Dundee’s performance was the poorest in the family group and poorer than the Scottish average.

National Indicator 6: Percentage of people with positive experience of the care provided by their GP practice (Scotland)

- 4 of the 8 (50%) family group partnerships performed the same as or better than the Scottish average.

- Dundee performed 4th best in the family group and the same as the Scottish average. National Indicator 7: Percentage of adults supported at home who agree that their services and support had an impact in improving or maintaining their quality of life. (Scotland)

- 4 of the 8 (50%) family group partnerships performed better than the Scottish average.

- Dundee’s performance was the 2nd poorest in the family group and poorer than the Scottish average. National Indicator 8: Percentage of carers who feel supported to continue in their caring role (Scotland)

- 6 of the 8 (75%) family group partnerships performed better than the Scottish average.

- Dundee’s performance was the 3rd poorest in the family group although it was slightly better than the Scottish average.

National Indicator 8: Percentage of carers who feel supported to continue in their caring role by year

- National Indicator 8 is the only one of the indicator set that can be analysed longitudinally.

- Every HSCP in the Family Group, including Dundee saw a decrease in the % of carers who felt supported to continue in their caring role from 2015-16 to 2019-20.

- This is the same trend for the Scottish average.

- Dundee maintained the same position in the family group between 2017-18 and 2019-20 at 3rd poorest in the family group. This is a deterioration from 2015-16 when Dundee was joint 4th poorest / best in the family group. National Indicator 9: Percentage of adults supported at home who agree they felt safe (Scotland)

- 4 of the 8 (50%) family group partnerships performed better than the Scottish average.

- Dundee’s performance was the 4th poorest in the family group and slightly poorer than the Scottish average. 1.0 PURPOSE OF REPORT

1.1 The purpose of this report is to provide the Performance and Audit Committee with an update on the progress of the actions set out in the Governance Action Plan.

2.0 RECOMMENDATIONS

It is recommended that the Performance and Audit Committee (PAC):

2.1 Notes the content of the report and the progress made in relation to the actions set out in the Governance Action Plan as outlined in Appendix 1 and supplemented in Appendices 2 and 3.

3.0 FINANCIAL IMPLICATIONS

3.1 None.

4.0 MAIN TEXT

4.1 The Governance Action Plan was presented and approved at the PAC meeting of the 25th March 2019 (Article VIII of the minute of the meeting refers) in response to a recommendation within Dundee Integration Joint Board’s Annual Internal Audit Report 2017/18. This action plan enables the PAC to regularly monitor progress in implementing actions and understand the consequences of any non-achievement or slippage in strengthening its overall governance arrangements. The PAC remitted the Chief Finance Officer to present an update progress report to each PAC meeting. This action plan has also been added to in order to reflect a range of actions arising from the recent Annual Internal and External Audit reports which formed part of the Annual Accounts and annual governance process for Dundee Integration Joint Board. The progress of the actions considered previously in the Governance Action Plan update is noted in Appendix 1.

4.2 The action plan from the External Audit Report for 2020-21 has been shown as Appendix 2

4.3 The individual actions highlighted in the Internal Audit Review as having been omitted from the Governance Action Plan around the Transformation Programme has been shown as Appendix 3. It should be noted however that the Transformation Delivery Group has been stood down following a review of its effectiveness and arrangements for the development, implementation and monitoring of service transformation are now remitted to the Strategic Planning Advisory Group which reconvened during 2020/21. Therefore some of these actions are no longer relevant. 5.0 POLICY IMPLICATIONS

5.1 This report has been screened for any policy implications in respect of Equality Impact Assessment and Risk Management. There are no major issues.

6.0 RISK ASSESSMENT

6.1 This report has not been subject to a risk assessment as it relates to the development of an action plan in line with the findings of the Annual Internal Audit Report.

7.0 CONSULTATIONS

7.1 The Chief Officer, Chief Internal Auditor and the Clerk were consulted in the preparation of this report.

8.0 BACKGROUND PAPERS

8.1 None.

Dave Berry Chief Finance Officer

DATE: 03 February 2021 | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Red: Not Started | Amber: In Progress | Green: Complete | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|---------------|--------------------------|-----------------|-------------------|-----------------|--------------------------|-----------------------------| | Audit Scotland Annual Audit Report 2018/19 (PAC 34-2019) 24th Sept 2019 | Arrangements should be implemented to provide assurance to the Chief Officer and the Board that the IJB that services are delivering Best Value. | Further learning from other IJB’s reporting with regards to Best Value to be gained and considered for reflection in the 2019/20 Annual Performance Report. | Chief Finance Officer June 2020 | GREEN | | | | | | Internal Audit Review – Information Governance (IG) & Technology as Enablers (PAC 24-2020) 22nd Sept 2020 | DHSCP should identify representation to the NHST Information Governance Cyber Security Committee | Identify appropriate representation to the NHST IG Cyber Security Committee | DHSCP Chief Officer 31/03/2020 | GREEN | | | | | | Internal Audit Review – Information Governance (IG) & Technology as Enablers | We strongly recommend that the pace of getting to an agreed position is increased. A Data / Information Sharing Agreement would provide the basis for | NHS Tayside’s Head of Information Governance and Cyber Assurance/Data Protection Officer to work with DCC’s Information Governance Manager to agree, disseminate and gain approval for a Data Sharing Agreement. The Data | NHS Tayside’s Head of Information Governance and Cyber Assurance/Data Protection Officer/ DCC’s Information Governance Manager | GREEN | | | | | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Red: Not Started | Amber: In Progress | Green: Complete | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|---------------|---------------------------|-----------------|-------------------|-----------------|--------------------------|-------------------------------| | (PAC 24-2020) 22nd Sept 2020 | determining appropriate access to systems and as a matter of urgency requires to be agreed and disseminated as appropriate. | Sharing Agreement will not cover specific systems. The Data Sharing Agreement should be considered by the Systems Application Strategy and Sharing Group which should develop policies and procedures for governing access to specific systems. | 31/03/2020 | | | | | | | Internal Audit Review – Information Governance (IG) & Technology as Enablers (PAC 24-2020) 22nd Sept 2020 | Given the need for NHST to engage with its partners across all 3 partnerships, it may be useful to establish a Tayside wide forum for this. In the meantime, where required, the possibility of interfaces sharing information between systems should be explored. Key corporate support services to be provided to DH&SCP by DCC and NHS Tayside has yet to be agreed. | Dundee HSCP’s MOSAIC Project / IT Board has been focussed on developing and implementing the MOSAIC case recording system since the inception of the HSCP. As the main system features have now been implemented the focus of this group will now move to identifying, prioritising and planning the integrated IT needs of the HSCP through the development of an IT strategy. IT leads from both NHST and DCC are invited members to this Board. The Board will provide the strategic direction with the WPE providing the technical response. | Chief Finance Officer DIJB 30 June 2020 | | | | | | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|--------------|--------------------------|--------------------------|-----------------------------| | Options should be explored in the context of the Improvement action plan developed in response to the MSG report and self-assessment. | Frequency of meetings of the Workplace Enablement (WPE) group will be increased to quarterly. A Bi-Yearly meeting will be established which will include Angus and PKC representation. It was agreed that the remit of the WPE Group was to remain a technical enablement forum. The DHSCP IT Board will set out the direction including the key issues highlighted in the MSG report. | NHST E-Health Service Delivery Manager, DCC IT Service Manager 30 June 2020 | GREEN | | | Internal Audit Review – Information Governance (IG) & Technology as Enablers (PAC 24-2020) 22nd Sept 2020 | DH&SCP should request that NHST review and update The NHS Systems Access Policy to ensure any issues encountered in the case of DH&SCP staff are covered as well as address any other findings of this report. | This policy is currently under review and will be submitted to the NHS Tayside Information Governance Committee in January 2020. If agreed this will then be submitted to the Audit and Risk Committee for final approval. | NHS Tayside’s Head of Information Governance and Cyber Assurance/Data Protection Officer 31 March 2020 | GREEN | | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|---------------|--------------------------|--------------------------|-------------------------------| | Internal Audit Review – Information Governance (IG) & Technology as Enablers (PAC 24-2020) 22nd Sept 2020 | Agreement should be reached through the Workplace Enablement Group (WEG), with DJB management to ensure that the process that HSCP staff follow to request access to partner’s systems, operates effectively and that the required support is provided by the partners. | This recommendation is already in progress. Workflows are required to be tested around off boarding of staff. | NHST E-Health Service Delivery Manager, DCC IT Service Manager 31 March 2020 | GREEN | | | Internal Audit Review – Information Governance (IG) & Technology as Enablers (PAC 24-2020) 22nd Sept 2020 | The role of this group should be reviewed with terms of reference. The group should have appropriate membership and be supported by both senior leadership commitment and clear escalation routes within the wider structures of DH&SCP, DCC and NHST. | Terms of Reference for the Workplace Enablement Group to be drawn up and agreed at the next meeting at the end of January 2020. | NHST E-Health Service Delivery Manager, DCC IT Service Manager 31 January 2020 | GREEN | |

Narrative shown in Italics denotes updated position from previous plan. Completed actions have been moved to the top of the plan for ease of use. | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|--------------|--------------------------|--------------------------|-----------------------------| | Audit Scotland Annual Audit Report 2018/19 (PAC 34-2019) 24th Sept 2019 | The IJB should: • review its processes for minute taking. | Further development of the IJB and PAC minutes and papers to ensure full transparency and accurate recording of the discussions, questions asked and assurances provided. | Chief Officer/ CFO/ Clerk to the Board September 2019 | GREEN | | | Dundee Integration Joint Board Clinical, Care and Professional Governance Internal Audit Review (PAC9-2018) 13th February 2018 | A review should be undertaken to establish or update the remits of the PAC, R2 and Forum in relation to clinical and care governance. The remits should set out reporting lines and be translated into annual work plans for each group. This should ensure reports, both for the purpose of assurance | Undertake review as outlined in the Audit Recommendations, setting out the remits of the PAC, R2 and Forum, and the reporting lines between all three. This process should also be followed for the Mental Health Governance Group to ensure appropriate lines of communication into the DHSCP governance processes. | Lead Allied Health Professional (Forum) Clinical Director (R2) Chief Finance Officer (PAC) Associate Nurse Director - Mental Health and Learning Disabilities | AMBER | Review of the CCPG forum and the CCPG Group has led to the development of primary governance groups under each locality manager. Each Primary Governance Group is to report directly into the CCPG Group. Terms of reference are in development for the primary governance groups, which link directly through CCPG Group and Clinical Quality Forum ensuring assurance process from service level to CQF. | March 2021 | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Red: Not Started | Amber: In Progress | Green: Complete | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|--------------|--------------------------|-----------------|-------------------|-----------------|--------------------------|-------------------------------| | as well as for implementation or delivery, go to the most appropriate group. | | | | | | | | | | Dundee Integration Joint Board Clinical, Care and Professional Governance Internal Audit Review (PAC9-2018) 13th February 2018 | In addition to the 6 domains of clinical and care governance across delegated services, this review of remits needs to consider: - Hosted services - Information Governance - Care Commission reports - Risk | Clarify and agree datasets and information to be presented at each group and associated timescales to ensure coordination of governance process. | Lead Allied Health Professional / Head of Service, Health and Community Care 30 June 2018 | AMBER | | | CCPG Forum will continue to operate as an avenue for service managers to share good practice and have dedicated space to discuss challenges across the Partnership. | December 2019 December 2020 | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Red: Not Started | Amber: In Progress | Green: Complete | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|--------------|--------------------------|-----------------|-------------------|-----------------|--------------------------|-------------------------------| | Dundee Integration Joint Board Clinical, Care and Professional Governance Internal Audit Review (PAC9-2018) 13th February 2018 | It is recommended that any new arrangements be considered and approved by the IJB or a nominated Committee/group. | The IJB will formally request that the Chair of the R1 Group advise the IJB of performance of R1 and any new arrangements to be implemented. Chief Officer of DJB to clarify reporting arrangements between R1 and IJB. Regular representation at the R1 and CQF will be provided from the R2 Group. | Chief Officer Lead Allied Health Professional / Head of Service, Health and Community Care 31 July 2018 (To allow time for R1 meetings to run). | AMBER | Working group established at Tayside level which will support and clarify reporting arrangements. A regular report is provided to the CQF and the Head of Service and/or Lead AHP attend to speak to the report at each meeting. | October 2019 March 2021 | | Dundee Integration Joint Board Clinical, Care and Professional Governance Internal Audit Review | Work undertaken to map out the assurance routes for the key domains should be further augmented by a mapping to the functions set out in the Appendix to the Integration scheme delegated functions will be mapped to ensure forum membership reflects the breadth of delegated functions. Service reports and performance data will reflect the breadth of the delegated | Lead Allied Health Professional / Head of Service, Health and Community Care 30 April 2018 | AMBER | Programme reporting covering all services will all be completed by June 2019. Schedule of services confirmed and membership extended to ensure all areas are | March 2021 | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Red: Not Started | Amber: In Progress | Green: Complete | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|--------------|---------------------------|-----------------|-------------------|-----------------|--------------------------|-------------------------------| | (PAC9-2018) 13th February 2018 | Integration Scheme, setting out all delegated functions, with priority given to the areas of highest importance/risk. | functions ensuring that reports to the IJB also reflect the breadth of the delegated functions. | | | | | considered by the R2 group. The development of the Primary Governance Groups will ensure comprehensive reporting across all aspects of the Partnership. There are a number of anomalies with some teams sitting outwith Locality Manager structures and these teams will report directly to CCPG Group. Further work to identify core and service datasets is ongoing, locally for DHSCP and across Tayside via the Getting it Right for Everyone Review Group. This work is nearing completion. | | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|---------------|--------------------------|--------------------------|-----------------------------| | DIJB Clinical, Care and Professional Governance Internal Audit Review (PAC9-2018) 13th Feb 2018 | Agreed levels of reporting should be reviewed against the governance principles appended to this report. | Further work will be done with the reporting templates to refine areas of common risk across the HSCP to support identification and mitigation of identified risks. | Lead Allied Health Professional / Head of Service, Health and Community Care 30 June 2018 | AMBER | Work continues to progress the reporting arrangements but not yet complete – revised timescale of end of December 2019. | March 2021 | | Dundee Integration Joint Board Workforce Internal Audit Review (PAC8-2018) 27th March 2018 | Work to fully implement the actions in the Workforce and Organisational Development Strategy should continue with regular reporting on progress towards implementation being submitted to the IJB. In addition, Locality Managers should strive towards ensuring that the | The DH&SCP management team fully recognises the need to ensure the vision and objectives of the Workforce and Organisational Development Strategy become embedded within the partnership and acknowledged that this is a fundamental element of the partnership’s continued development. Implementing in full the actions in the Strategy has been identified by the operational management team as one of the key actions to be delivered over the next 6 months. | Head of Health and Community Care / Head of Finance and Strategic Planning August 2018 | RED | Review of Workforce and Organisational development strategy as companion document to the review of Strategic Plan. | March 2021 | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Red: Not Started | Amber: In Progress | Green: Complete | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|---------------|---------------------------|-----------------|-------------------|-----------------|--------------------------|-------------------------------| | DH&SCP culture becomes fully embedded. | | | | | | | | | | Engaging staff in developing and maintaining the partnership culture as well as sharing and embedding the guiding principles should assist with this. | | | | | | | | | | Consideration should be given to developing a formal Service Level Agreement (SLA) detailing all key corporate support services to be provided to the DH&SCP by Dundee City Council and NHS Tayside. | | | | | | | | | | The DHSCP Management Team continues to monitor the level of support being provided to the IJB from NHS Tayside and Dundee City Council on an informal basis and responds to the organisations in relation to shortfalls in service provision accordingly. | | | | | | | | | | Given the current stage in the partnership’s development, with greater knowledge and awareness of what the | | | | | | | | | The service provided should be regularly reviewed along with the SLA to ensure that the defined support is being provided and the SLA continues to be appropriate. In the absence of a SLA, specific details regarding the types and level of support expected should be clearly documented and formally agreed by senior management at the DH&SCP, Dundee City Council and NHS Tayside.

Regular reports on the support service requirements should be provided to the IJB.

| Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Red: Not Started | Amber: In Progress | Green: Complete | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|---------------|---------------------------|-----------------|-------------------|-----------------|--------------------------|-------------------------------| | The service provided should be regularly reviewed along with the SLA to ensure that the defined support is being provided and the SLA continues to be appropriate. In the absence of a SLA, specific details regarding the types and level of support expected should be clearly documented and formally agreed by senior management at the DH&SCP, Dundee City Council and NHS Tayside. Regular reports on the support service requirements should be provided to the IJB. | partnership needs to support its business, the service will progress with its partners, a more formal statement of the expected level of support which can subsequently be monitored and report to the IJB. | | | | | | | | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Red: Not Started | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|--------------|--------------------------|-----------------|--------------------------|-------------------------------| | Dundee Integration Joint Board Workforce Internal Audit Review (PAC8-2018) 27th March 2018 | Future workforce plans for DH&SCP should include plans for all areas of delegated responsibility, tailored to deliver the relevant elements of the Strategic Plan. Plans should take account of demand for and availability of staff to maximise the use of resources within the DH&SCP. | As DH&SCP continues to evolve, with the continued development of integrated locality-based services and redesign of services, the shape and mix of the workforce required to deliver on the IJB’s strategic objectives is becoming clearer and will be reflected in future integrated workforce plans. While acknowledging that further national guidance is awaited on this matter, the first integrated workforce plan will be developed over the next 6 months. | | | | | | Action Plan in Response to the Services for Older People (Edinburgh) Inspection Report | Action Plan was requested by the PAC in relation to lessons learned from the Edinburgh inspection and what improvements would | A wide range of actions are reflected in this detailed action plan therefore it is not feasible to reflect in this plan – a separate update report will be provided at the May 2019 PAC. | Various with latest timescales for completed action identified as March 2019. | RED | Report to now be presented to the March 2020 PAC meeting Work on collating and rationalising improvement plans and action plans is underway in recognition that a | March 2021 | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Red: Not Started | Amber: In Progress | Green: Complete | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|---------------|--------------------------|-----------------|-------------------|-----------------|--------------------------|-------------------------------| | (PAC 29-2018) 29th May 2018 | be required in Dundee. | | | | | | number of issues have not been actioned. | | | Risk Management Action Plan | Action Plan was required to respond to the findings of the Risk Maturity Assessment presented to the PAC on the 25th September 2018. | A wide range of actions are reflected in this detailed action plan therefore it is not feasible to reflect in this plan. A separate update report will be provided to the September 2019 PAC meeting as agreed. | Chief Finance Officer September 2019 | AMBER | Report DIJB37-2020 presented to the August 2020 IJB Discussions held between risk management functions of Dundee City Council and NHS Tayside to agree way forward for actions. Follow up meetings with partners across Tayside scheduled to enable actions to be completed A separate report to the PAC has been presented September 2020 | | | 2017/18 Annual Internal Audit Report – Action Plan Update (PAC7-2019) | Clarification of deputising arrangements for the Chief Officer to be presented to the IJB. | Agreement to be reached between Chief Executives of Dundee City Council and NHS Tayside. | Revised February 2019. | RED | Discussion to be held between Chief Executives | December 2020 | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|--------------|--------------------------|--------------------------|-----------------------------| | 12th February 2019 | Consideration should be given to providing the IJB with reporting on workforce issues including the Workforce and Organisational Development Strategy as well as the partnership forum. | Complete review of Workforce and Organisational Development Strategy and provide update to IJB. Consider frequency and content of update report of activities of Staff Partnership Forum. | Revised April 2019 | AMBER | Updated Workforce and Organisational Development Plans, compatible with the revised Strategic and Commissioning Plan due to be presented to the IJB in February 2020. | March 2021 | | 2017/18 Annual Internal Audit Report – Action Plan Update (PAC7-2019) 12th February 2019 | Development of Large Hospital Set Aside arrangements in conjunction with the Scottish Government, NHS Tayside and Angus and Perth and Kinross Integration Joint Boards. | Work progressing with NHS Tayside in association with the 3 Tayside IJB Chief Finance Officers and Scottish Government to conclude the methodology or determining and monitoring the Large Hospital Set Aside to inform commissioning decisions as set out within the legislation. | Revised - March 2019 | AMBER | Value of Large Hospital Set Aside agreed for inclusion in 2020/21 budget including recognition of improvements made by Dundee HSCP in reducing emergency bed days resulting in the release of £1m of funding from NHS Tayside to Dundee IJB’s | March 2021 | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Red: Not Started | Amber: In Progress | Green: Complete | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|--------------|--------------------------|-----------------|-------------------|-----------------|--------------------------|-------------------------------| | 2017/18 Annual Internal Audit Report – Action Plan Update (PAC7-2019) 12th February 2019 | Development of improved Hosted Services arrangements around risk and performance management for hosted services. | Current hosted services arrangements subject to discussion across the 3 Tayside Chief Officers and Chief Finance Officers. Proposal to be brought forward to IJB and PAC before the end of the financial year. | Revised June 2019 | AMBER | Discussions ongoing with neighbouring IJB’s re responsibilities around hosting arrangements. | March 2021 | | 2017/18 Annual Internal Audit Report – Action Plan Update (PAC7-2019) 12th February 2019 | Further develop the Integration Joint Board’s local Code of Governance. | To be developed as suggested. | Revised April 2019 | AMBER | Clerk to the Board developing arrangements in conjunction with Chief Finance Officer. Actions postponed as a result of pandemic working restrictions | December 2020 | | 2017/18 Annual Internal Audit | Further develop performance report information into a | To be taken forward by the Strategy and Performance Team, aligned with the review | Revised July 2019 | AMBER | Will form part of revised performance monitoring reporting into 2019/20 | | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|--------------|--------------------------|--------------------------|-----------------------------| | Report – Action Plan Update (PAC7-2019) 12th February 2019 | delivery plan framework to ensure IJB fulfils its remit in delivering the direction of travel within the Strategic Commissioning Plan. | of the Strategic and Commissioning Plan. | | following approval of revised Strategic and Commissioning Plan. Work has started on performance against 4 high level indicators in plan. Needs further development in line with any revisions to the SPG structure. | March 2021 | | Audit Scotland Annual Audit Report 2018/19 (PAC 34-2019) 24th Sept 2019 | A long-term financial strategy (5 years or more) supported by clear and detailed financial plans (3 years or more) should be prepared. | Build on the three-year financial framework developed during 18/19, which sets out the estimated resources and anticipated increase in expenditure from rising demand and costs of providing services. Continue to work with partner bodies to align longer term financial planning processes and the development of long-term financial strategy on how to close the gap between funding and service provision. | Chief Finance Officer March 2020 | AMBER | Work continues to develop the longer-term financial framework as part of the budget setting process. | December 2020 | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Red: Not Started | Amber: In Progress | Green: Complete | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|--------------|--------------------------|-----------------|-------------------|-----------------|--------------------------|-------------------------------| | Audit Scotland Annual Audit Report 2018/19 (PAC 34-2019) 24th Sept 2019 | The IJB should liaise with NHS Tayside and consider the arrangements for regular attendance by a member appointed as the registered medical practitioner providing primary care. | NHS Tayside Board is responsible for appointing the role of registered medical practitioner providing primary care to the IJB. This issue has been noted by the IJB and the Clerk to the Board will formally write to the Chair of NHS Tayside Board on this issue. | Clerk to the Board December 2019 | AMBER | Clerk has written to NHS Tayside and awaits a formal response. 23-01-20 NHS have not confirmed a replacement for Registered Medical Practitioner as yet. (NHS have also to confirm replacement for one voting member on Dundee IJB. | November 2020 | | Audit Scotland Annual Audit Report 2018/19 (PAC 34-2019) 24th Sept 2019 | The IJB should liaise with its partner organisations to ensure an agreed budget is approved prior to the start of the year. | An indicative NHS Budget was provided at the IJB budget meeting of 30th March 2019. The final budget from NHS Tayside was consistent with the indicative budget. Continue to work with partner bodies to align budget setting processes as far as practicable. | Chief Finance Officer March 2020 | AMBER | Continues to be discussed at budget meetings with the parties. Timescale impacted by Covid-19 response for 2020/21 budget | March 2021 | | Audit Scotland Annual Audit Report 2018/19 (PAC 34-2019) | The IJB should seek to combine financial and performance reporting to ensure that members have clear sight of the | Continue to explore options on how to combine financial and performance reporting in a format which provide useful information to users. | Chief Finance Officer March 2020 | AMBER | Progressing slower than as planned as a result of Covid-19 required changes to working | March 2021 | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Red: Not Started | Amber: In Progress | Green: Complete | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|--------------|---------------------------|-----------------|-------------------|-----------------|--------------------------|-------------------------------| | 24th Sept 2019 | impact of variances against budget in terms of service performance. | | | | | | | | | Audit Scotland Annual Audit Report 2018/19 (PAC 34-2019) 24th Sept 2019 | The IJB should review its reserves to ensure they are adequate | Reserves can only be accumulated through year end surpluses of funding. Ensure robust budgeting, monitoring of identified savings and financial monitoring processes in place to identify opportunities to enhance reserves position. | Chief Finance Officer March 2020 | AMBER | Levels of uncommitted reserves are anticipated to reduce in response to the anticipated overspend. Reserves have been reviewed and are inadequate in terms of the Reserves Policy. IJB unlikely to be in a position of increasing reserves given current budget pressures | March 2021 | | 2019/20 | Implementation of and reporting on all outstanding recommendations arising from the Ministerial Steering Group report on Health & social care Integration | | Chief officer/ Chief Finance Officer | AMBER | | | March 2021 | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|--------------|--------------------------|--------------------------|-------------------------------| | 2019/20 | Further development of governance arrangements considering agreed governance principles and updated advice from the Scottish Government Health & Social care Division | Chief officer/Chief Finance Officer | AMBER | December 2020 | | Internal Audit Review – Information Governance (IG) & Technology as Enablers (PAC 24-2020) 22nd Sept 2020 | Clear escalation routes should be agreed between DJB and its partners for Information Governance and e-Health (IT) | Establish a governance route | NHS Tayside Head of Information Governance and Cyber Assurance/Data Protection Officer 31/03/2020 | AMBER | March 2021 | | Internal Audit Review – Information Governance (IG) & Technology as Enablers | IT services within the Council and NHS Tayside, along with representatives from DH&SCP, should meet regularly when key IT development | Strategic discussions will be held between all partners in conjunction with Scottish Government to help facilitate an operational solution through the provision of available funding / resources. | Executive Director of Corporate Services DCC Director of Digital Technology NHST | AMBER | March 2021 | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|--------------|--------------------------|--------------------------|-----------------------------| | (PAC 24-2020) 22nd Sept 2020 | decisions are being taken and any IT problems that arise due to the unique circumstances of the DH&SCP can be discussed and resolved timeously. | Chief Finance Officer, DJB 30 June 2020 | | | | | Internal Audit Review – Information Governance (IG) & Technology as Enablers (PAC 24-2020) 22nd Sept 2020 | Future meetings of the group considering IT developments should also include discussion on an IT helpdesk agreement for DH&SCP staff as well as agreement on the processes for sharing information on DH&SCP staff active directory users. It may be useful to establish a Tayside wide forum for this. | A Bi-Annual Meeting to be arranged. | NHST E-Health Service Delivery Manager 30/11/2020 | AMBER | | | Internal Audit Review – Governance Mapping | The DHSCP management team should review attendance at groups | The evolving complexity of integrated arrangements are such that the capacity of the management team of the Health and Social Care | Chief Officer, Dundee HSCP 31/03/2021 | RED | | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Red: Not Started | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|--------------|--------------------------|-----------------|--------------------------|-----------------------------| | (PAC28-2020) 22nd Sept 2020 | based on agreed principles. Equally, attendance at partner groups should be based on a consideration of whether this is necessary to provide assurance to allow the partner body to fulfil their agreed responsibilities in line with their accountabilities. | Partnership in its widest sense is insufficient to effectively contribute to all the demands placed on it through partner groups in particular. The development of a range of principles as recommended will provide a better structured approach and through the shared understanding of the partners of priorities, provide the necessary assurances to them. This will be actioned as recommended. | | | | | Internal Audit Review – Governance Mapping (PAC28-2020) 22nd Sept 2020 | A best practice guidance document is developed to ensure the operation of all groups conforms to the various principles detailed in the report. | A best practice guidance document would be beneficial and will be developed as recommended | Head of Finance & Strategic Planning, Dundee HSCP 31/03/2021 | RED | | | Internal Audit Review – | A review should be undertaken to update the strategic | The risk and associated controls will be reviewed as recommended | Head of Finance and Strategic Planning, Dundee HSCP | RED | | | Performance and Audit Committee Report | Audit Recommendation | Agreed Action | Original Action By / Date | Red: Not Started | Amber: In Progress | Green: Complete | Remedial Action/Comments | Revised Target Completion Date | |----------------------------------------|----------------------|--------------|---------------------------|-----------------|-------------------|-----------------|--------------------------|-------------------------------| | Governance Mapping (PAC28-2020) 22nd Sept 2020 | risk in relation to Increased Bureaucracy. | | 31/03/2021 | | | | | | | PAC 36-2020 Audit Scotland Annual Report And Integration Joint Board Annual Accounts 2019/20 24th Nov 2020 | | | | | | | | | The abbreviations etc. in the governance action plan are as used in the various audit reports and vary slightly depending on the report author:

| Abbreviation | Description | |--------------|-------------| | The Board | The Integration Joint Board | | DCC | Dundee City Council | | DHSCP | Dundee Health & Social Care partnership | | HSCP | Health & Social Care Partnership | | IG | Information Governance | | IJB | Integration Joint Board | | IT | Information Technology | | MOSAIC | Name of the computerised case recording system used by DHSCP | | NHS | National Health Service | | NHST | National Health Service Tayside | | TDG | Transformation Delivery Group |

## Action plan 2019/20

| No. | Issue/risk | Recommendation | Agreed management action/timing | Remedial Action/Comments | Revised Target Completion Date | |-----|------------|----------------|---------------------------------|--------------------------|-------------------------------| | 1 | Medium to long term financial plans | The 1-5-year financial plan should be progressed and presented to the Board to help demonstrate the longer term financial sustainability of planned IJB services. This is increasingly important as demand pressures increase and the IJB plans for service redesign over medium and longer time frames. Plans should include scenario planning in the Covid-19 environment. Paragraph 44 | The development of a meaningful medium to longer term financial plan has been impacted on by significant uncertainty around funding with delays in UK and Scottish Government finance settlements for both 2020/21 and 2021/22 and the impact of Covid19 in 2020/21 disrupting the planning process. A medium to long term financial plan will be developed and presented to the IJB as part of a suite of budget development reports for 2021/22 onwards. Responsible officer: Chief Finance Officer Agreed date: March 2021 | Amber | | | No. | Issue/risk | Recommendation | Agreed management action/timing | Remedial Action/Comments | Revised Target Completion Date | |-----|---------------------------------------------------------------------------|--------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------|--------------------------|-------------------------------| | 2 | **Savings and transformation reporting** | The position on the achievement of savings proposals and transformation should be clearly and regularly reported to members. The impact from Covid-19 and delivering pandemic remobilisation plans will also need to be considered. Paragraph 69 | The IJB is provided with an overview of the risks of delivery associated with the savings programme as part of regular financial monitoring reports presented to the IJB. This will be enhanced during the year with a minimum of two specific savings and transformation reports outlining the progress made with implementation of service change initiatives. Responsible officer: Chief Finance Officer Agreed date: August 2021 | Amber | | | 3 | **Leadership and governance - support Plans to progress a programme of development and training opportunities for members, co-ordinated alongside those of Dundee City Council and NHS Tayside** | Work to embed a programme of development and training opportunities for Board members should be progressed. Paragraph 77 | A programme of coordinated work which brings together the individual pieces of development and training opportunities already in existence and under new development opportunities under one | Amber | | | No. | Issue/risk | Recommendation | Agreed management action/timing | Remedial Action/Comments | Revised Target Completion Date | |-----|---------------------------------------------------------------------------|--------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------|--------------------------|-------------------------------| | | has not progressed to the extent planned. | | framework will be produced with the respective statutory partners. Responsible officer: Chief Officer Agreed date: June 2021 | | | | | Risk | There is a risk that leadership and governance arrangements are not effective if members are not sufficiently trained and supported. | | | | | 4 | Board composition - registered medical practitioner providing primary care | The IJB should escalate to NHS Tayside again, that the IJB has not had professional input from a 'registered medical practitioner whose name is included in the list of primary medical services performers' for a number of years and request NHS Tayside appoint to this non-voting role. Paragraph 79 | Both the Clerk to the IJB and the Chair of the IJB have written to NHS Tayside to request a nomination to this role. The IJB will continue to make this request however it is the role of NHS Tayside to provide an appropriate nomination. Responsible officer: Clerk to the Board / Chief Officer Agreed date: December 2020 | Amber | | | No. | Issue/risk | Recommendation | Agreed management action/timing | Remedial Action/Comments | Revised Target Completion Date | |-----|------------|----------------|---------------------------------|--------------------------|-------------------------------| | 5 | Improvement agenda - action plan progress | From its inception the IJB has experienced significant delays in progressing its improvement and governance actions. This issue has been escalated to the Board from the PAC. | The Governance Action Plan should be developed to include all improvement action plans. Actions should be reviewed for their continued relevance and priority. The Board and PAC should continue to be updated on implementation progress across all governance and improvement areas. Paragraph 91 | All improvement actions now included within the Governance Action Plan which is reported to the PAC at each meeting. Assurance to the IJB from the PAC will be provided on satisfactory progress being made in implementing the outstanding recommended actions. Responsible officer: Chief Finance Officer Agreed date: December 2020 | Green | | 6 | Risk management | Progress has been slow to implement the recommendations from the internal risk maturity audit, reported in September 2018. Recently a Tayside Risk Management Group chaired by the CFO has been established to promote | The Board and PAC are updated on progress in delivering against the risk maturity action plan. Paragraph 98 | As reported in the Governance Action Plan, progress is now being made with full implementation of the recommendations to be achieved by March 2021. | Amber | | No. | Issue/risk | Recommendation | Agreed management action/timing | Remedial Action/Comments | Revised Target Completion Date | |-----|------------|----------------|---------------------------------|--------------------------|-----------------------------| | | completion of the actions by December 2020. | Supported by management, the delivery of internal audit plans should be kept under review to ensure the IJB receives appropriate and sufficient assurances on its governance arrangements and systems of its internal controls. Paragraph 105 | Responsible officer: Chief Finance Officer Agreed date: March 2021 | | | | 7 | Internal audit - programme | The re-profiling of the 2020/21 internal audit plan reduces the risk of non-delivery of the plan and enables future plans to be achieved in line with the anticipated timescales, providing the IJB and PAC with the appropriate assurances. Progress of the internal audit plan will continue to be monitored through the internal audit progress report provided to each meeting of the PAC. | | Green | | | No. | Issue/risk | Recommendation | Agreed management action/timing | Remedial Action/Comments | Revised Target Completion Date | |-----|------------|----------------|---------------------------------|--------------------------|-------------------------------| | | | | Red: Not Started | Amber: In Progress | Green: Complete | | | | | | Responsible officer: Chief Finance Officer / Chief Internal Auditor | Agreed date: December 2020 | | |

**Follow up of prior year recommendations**

**PY 1**\
**Financial accounting records**\
The financial ledger had not been fully updated to reflect all accounting entries prior to the production of the annual accounts.\
**Risk:** Accounting records may not include all the transactions and balances to reflect a true and fair view of the IJB’s accounts.\
The financial ledger should be fully updated in 2019/20 prior to the approval of the annual accounts. Paragraph 17\
**Complete**\
The ledger was fully updated in 2019/20.\
**Green**

**PY 2**\
**Failure to comply with statutory regulations**\
The Chief Officer was on leave until after 30 September 2019. As a result, the accounts were not signed, approved and\
The arrangements for the approval of the accounts should be reviewed to ensure that all signatories are available to sign the accounts immediately after they are approved by the Performance and Audit Committee. Paragraph 21\
**Complete**\
The CFO reviewed arrangements to ensure the availability of officers and members to ensure the\
**Green** | No. | Issue/risk | Recommendation | Agreed management action/timing | Red: Not Started | Amber: In Progress | Green: Complete | Remedial Action/Comments | Revised Target Completion Date | |-----|---------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------|------------------|-------------------|-----------------|--------------------------|-------------------------------| | | authorised for issue until after the statutory date set out in the Local Authority Accounts (Scotland) Regulations 2014. | requirements of the regulations as met. | | | | | | | | | Risk: The IJB are not complying with statutory regulations. | | | | | | | | | PY 3| Medium to long term financial plans | A long-term financial strategy (5 years or more) supported by clear and detailed financial plans (3 years or more) should be prepared. This is increasingly important as demand pressures increase, financial settlements continue to reduce and fundamental service redesign over a longer time frame becomes necessary. Plans should include scenario planning. Paragraph 41 | In progress Carried forward to action 1 above. | Carried forward to action 1 above | | | | | | | The Board approved a Strategic and Commissioning Plan 2019-22 in March 2019, which projected funding shortfalls for the three year period. The IJB has yet to develop medium to long term financial plans to demonstrate how it will fund future funding gaps. | | | | | | | | | | Risk: The IJB may not be planning adequately over the medium to long term to manage or respond to significant financial risks. | | | | | | | | | No. | Issue/risk | Recommendation | Agreed management action/timing | Red: Not Started | Amber: In Progress | Green: Complete | Remedial Action/Comments | Revised Target Completion Date | |-----|---------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------|-----------------|-------------------|-----------------|--------------------------|-------------------------------| | PY 4 | Savings reporting The IJB reports changes to the risk profile of savings but does not report to members on the savings achieved and whether delivery is on track. Risk: Members may not be fully aware of the impact of not delivering savings. | The position of the achievement of savings proposals and the impact on the transformation programme should be regularly reported to members. Paragraph 47 | In progress Carried forward to action 2 above. | Carried forward to action 2 above | | | | | | PY 5 | EU withdrawal The risks entailed by EU withdrawal are not included in the IJB’s strategic risk register but continue to sit with the partner bodies. Risk: The IJB may not be adequately mitigating risks to its operation arising from EU withdrawal. | The risks arising from EU withdrawal should be included in the IJB’s strategic risk register and, as commissioning authority, the IJB should seek to ensure, that satisfactory arrangements have been put in place by partner bodies to manage potential risks. Paragraph 53 | Complete Strategic Risk Register presented to August 2020 Board included a risk on the impact of EU withdrawal. Note: the risk register noted that the impact of the Covid-19 response has meant the preparations for the EU withdrawal have been unable to be progressed. | Green | | | | | | PY 6 | Clinical, Care and Professional Governance Group Assurance Reports In September 2018, the Performance and Audit | Chair’s Assurance Report from the Clinical, Care and Professional Governance Group should be presented to the Performance and Audit Committee on a regular basis. | Complete A Chair’s Assurance Report from the Clinical, Care and Professional | Green | | | | | | No. | Issue/risk | Recommendation | Agreed management action/timing | Remedial Action/Comments | Revised Target Completion Date | |-----|---------------------------------------------------------------------------|----------------|---------------------------------|--------------------------|-------------------------------| | | Committee received its first Chair’s Assurance Report from the Clinical, Care and Professional Governance Group. No CCPG Assurance Reports were provided to the March 2019 or May 2019 Performance and Audit Committee meetings. Risk: The Board does not have complete and sufficient assurances on clinical care governance. | Paragraph 59 | Governance Group is now considered at each Performance and Audit Committee meeting. | | | | PY 7 | Board attendance The registered medical practitioner providing primary care, a non-voting member of the IJB, has been unable to attend the majority of meetings in the last year. Risk: Appropriate professional care expertise may not be considered by the Board. | The IJB should liaise with NHS Tayside and consider the arrangements for regular attendance by a member appointed as the registered medical practitioner providing primary care. Paragraph 60 | Incomplete Carried forward to action 4 above. | Carried forward to action 4 above | | No. | Issue/risk | Recommendation | Agreed management action/timing | Remedial Action/Comments | Revised Target Completion Date | |-----|---------------------------------------------------------------------------|--------------------------------------------------------------------------------|---------------------------------|--------------------------|-------------------------------| | | | Management should review the interaction with internal audit to ensure that all planned internal audit work is completed timeously. Paragraph 77 | In progress Carried forward to action 7 above. | Carried forward to action 7 above | | | PY 8 | Internal audit There continues to be slippage in reporting on internal audit work to the Performance and Audit Committee. Risk: Members may not be able to scrutinise key risk areas timeously if internal audit reports are delayed. | The Governance Action Plan progress report should be further developed to include all improvement action plans. Paragraph 78 | Incomplete Carried forward to action 5 above. | Carried forward to action 5 above | | | PY 9 | Action plan progress report Since March 2019 a Governance Action Plan progress report has been presented to the Performance and Audit Committee. The report does not include all improvement action plans. Risk: The commitments set out in the IJB’s Strategic Commissioning Plan may not be delivered timeously if improvement actions are not delivered within the agreed timescales. | | | | | | Ref | Audit Recommendations | Actions Proposed | Responsible Officer | Timescales | Remedial Action/Comments | Revised Target Completion Date | |-----|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------|-------------------|----------------------------------------------------------------------------------------|--------------------------------| | 1. | To improve existing review and monitoring arrangements surrounding progress towards delivery and realisation of the DHSCP’s Transformation Programmes and individual projects contained within them, an overarching record comprising, as a minimum, the following key pieces of information should be introduced and maintained. When developing the overarching record, appropriate consideration should be given to the transformational change programmes in place within Dundee City Council and NHS Tayside. This record, which should be reviewed on a regular basis by key members of staff and groups, including the Transformation Delivery Group (TDG), should provide users with implementation status information at a glance. Transformation Programme, along with brief description. • List of each transformation | The existing documentation supporting the Transformation Programme will be enhanced to ensure the areas suggested in the audit recommendation are included along with appropriate implementation status indicators. Performance monitoring will be supported through the use of the Pentana performance monitoring system. This will enable project leads and other stakeholders to track progress of implementation. | Chief Finance Officer / Head of Health and Community Care Services | 31st August 2019 | Amber | August 2021 | | 2. | Given that the TDG aims to drive delivery and realisation of the Transformation Programme in general and the individual projects within it, it is vital that these meetings are not cancelled and that there is ongoing engagement at the meetings from all relevant individuals and groups. With that in mind, where standing members of the group are not available to attend a meeting, they should ensure that an appropriate substitute attends / makes decisions on their behalf. This requirement should be stipulated in the TDG Terms of Reference, which should be endorsed by the TDG prior to approval by the PAC. | Review of governance meetings and interrelationships has been initiated to ensure the most effective governance routes for policy and decision making. This includes reviewing the clearance route for papers to be presented to the IJB and PAC, Clinical and Care Governance Forum, relationships between strategic planning groups, the ISPG and the subsequent oversight of transformation in line with the Strategic and Commissioning Plan. This will provide more clarity on responsibilities and is likely to result in a rationalisation of meeting structures with the strong possibility that the Transformation Delivery | Dundee Health and Social Care Partnership Management Team | 30th June 2019 | Amber | Now being considered by the Strategic Planning Advisory Group | August 2021 | | | | | | | |---|---|---|---|---| | 2 contd | In order to enhance existing governance arrangements, fulfil the Terms of Reference of the TDG and assist with prioritising resources, regular summary reports on the progress of the Transformation Programme should be prepared by the TDG and submitted to the Performance and Audit Committee for its review. The Terms of Reference of the PAC should be updated to reflect the requirement for the TDG to report to it. | This recommendation will be considered as part of the review noted above. | Dundee Health and Social Care Partnership Management Team | 30th June 2019 | Amber | | | | | | | | 3. | Terms of Reference documents should be developed / reviewed for all groups that impact on the transformation and service redesign arrangements of the DH&SCP, including the Integrated Strategic Planning Group. These should clearly detail the roles, remits and governance arrangements of the group, who they are required to report to and under what circumstances. An overarching review of reporting requirements should be carried out in relation to the Transformation Programme. As part of this exercise, clarity should be provided surrounding the groups that | This recommendation will be considered as part of the review noted above, including an assessment of the range and structure of the various client and theme based strategic planning groups. Please note development of terms of reference will take longer to establish hence the later action by date | Dundee Health and Social Care Partnership Management Team | 30th September 2019 | No longer relevant due to TDG being stood down. Terms of reference for relevant transformation groups to be considered under the response to Governance Mapping Internal Audit Report presented to the September 2020 PAC | | Transformation proposals should be presented to the groups / governing bodies and committees (i.e. IJB and Performance and Audit Committee) that should give approval to proceed with those proposals and the groups that require to be copied into proposals for information only | The existing documentation supporting the Transformation Programme will be enhanced to ensure the areas suggested in the audit recommendation are included | Chief Finance Officer / Head of Health and Community Care Services | 31st August 2019 | No longer relevant due to TDG being stood down. | |---|---|---|---|---| | 4. Any reports prepared as part of the Transformation Programme and Transformation Workstreams should specifically include a section on for noting the potential impact of the transformation programme / project on quality and make specific reference to the consideration being given as to the impact on clinical or / social work standards. | A comprehensive summary of the 2019/20 savings proposals methodology will be developed as part of the final 2019/20 budget development source files | Chief Finance Officer | 30th June 2019 | Green | | 5. To assist with ensuring that efficiency savings can be easily identified, explained and tracked as they progress, sufficient demonstrable evidence, including the methodology and principles applied to arrive at the figures, should be available / retained | This recommendation was implemented in 2018/19 and budget adjustments will be made timeously to the ledger for 2019/20 for those savings identified | Chief Finance Officer | 30th June 2019 | Green | | accordingly in NHS Tayside’s general ledger. | as being in relation to NHS provided services/expenditure | | | | 1.0 PURPOSE OF REPORT

1.1 The purpose of this report is to provide the Performance and Audit Committee with a progress update in relation to the current Internal Audit Plan.

2.0 RECOMMENDATIONS

It is recommended that the Performance & Audit Committee (PAC):

2.1 Notes the continuing delivery of the audit plan and related reviews as outlined in this report.

3.0 FINANCIAL IMPLICATIONS

3.1 None.

4.0 MAIN TEXT

4.1 As approved under the essential business procedure and formally noted by Dundee IJB at its meeting of the 25th August 2020 (Report PAC15-2020), during 2020/21, Internal Audit Activity will focus on the previously agreed audits with updated scopes agreed with management.

4.2 As per Audit Scotland’s recommendation and subsequent agreed action following the Dundee IJB External Audit Annual Report 2016/17, presented to the September 2017 Performance and Audit Committee (PAC21-2017), progress of the Internal Audit Plan is now a standing item on Performance and Audit Committee agendas.

4.3 An update on the progress of all the IJB’s Internal Audits is shown in Appendix 1.

- Finance (D05/19): Final report issued. See item 8 on this agenda
- Performance management (D05/20): Fieldwork stage
- Adverse events management (D06/20): Planning stage.

5.0 POLICY IMPLICATIONS

5.1 This report has been screened for any policy implications in respect of Equality Impact Assessment. There are no major issues.

6.0 RISK ASSESSMENT

6.1 This report has not been subject to a risk assessment as it a status update and does not require any policy or financial decisions at this time. 7.0 CONSULTATIONS

7.1 The Chief Officer, Regional Audit Manager and the Clerk were consulted in the preparation of this report.

8.0 BACKGROUND PAPERS

8.1 None.

Dave Berry Chief Finance Officer

Date: 08 January 2021 | Ref | Audit | Indicative Scope | Target Audit Committee | Planning Commenced | Work in Progress | Draft Issued | Completed | Grade | |-------|------------------------|----------------------------------------------------------------------------------|------------------------|--------------------|------------------|--------------|-----------|-------------| | D01-19| Audit Planning | Agreeing audit universe and preparation of strategic plan | N/A | Complete | Complete | Complete | Complete | N/A | | D02-19| Audit Management | Liaison with management and attendance at Audit Committee | N/A | | | Complete | | | | D03-19| Annual Internal Audit Report | Chief Internal Auditor's annual assurance statement to the IJB and review of governance self-assessment | N/A | Complete | Complete | Complete | Complete | N/A | | D04-19| Information Governance | Review of IT/ data processes supporting the delivery of the IJB's strategic plan through seamless cross system working | September 2020 | Complete | Complete | Complete | Complete | D | | D05-19| Finance | Review of arrangements established to control and mitigate Risks 1&2 from the high level risk register | February 2021 | Complete | Complete | Complete | Complete | Limited Assurance | | D06-19| Governance & Assurance | Governance mapping exercise: Assess the extent to which the IJB’s structures support the delivery of strategic objectives Includes review of controls to address Risk 7 | September 2020 | Complete | Complete | Complete | Complete | Limited Assurance | | Ref | Audit | Indicative Scope | Target Audit Committee | Planning Commenced | Work in Progress | Draft Issued | Completed | Grade | |-------|------------------------|----------------------------------------------------------------------------------|------------------------|--------------------|------------------|--------------|-----------|-------| | D01-20 | Audit Planning | Preparation of Annual Internal Audit Plan | | September 2019 | Complete | Complete | Complete | N/A | | D02-20 & D02-21 | Audit Management | Liaison with management and attendance at Performance and Audit Committee | N/A | | | Ongoing | | | | D03-20 & D03-21 | Annual Internal Audit Report | Chief Internal Auditor's annual assurance statement to the IJB and review of governance self-assessment | June 2019 August 2020 | Complete | Complete | Complete | Complete | N/A | | D04-20 | Governance & Assurance | Ongoing support and advice on further development of governance and assurance structures, including issues identified as part of the annual report process and the self assessment against the Ministerial Strategic Group report and help in implementing an audit follow up process | N/A | | | Ongoing | | | | D05-20 | Performance management | Adequacy, accuracy, relevance, reliability, data quality, timeliness and interpretation of reporting against the priorities in the Strategic and Commissioning Plan and core integration indicators. Compliance with DL 2016 (05) - Guidance for Health and Social Care Integration Partnership Performance Reports and preparation for/implementation of the anticipated new national guidance on the ‘Joint Accountability Framework’ | May 2021 | Complete | Complete | | | | | D06-20 | Adverse events management | This work will link to Operational risks 30 and 34. Risk of duplication or omission at the interface of NHS and Local Authority Adverse event management processes and systems. Effective sharing of learning from reviews. Clear flow of assurance | May 2021 | Ongoing | 1.0 PURPOSE OF REPORT

1.1 The purpose of this report is to present the findings of the Internal Audit Review of Finance to the Performance and Audit Committee.

2.0 RECOMMENDATIONS

It is recommended that the Performance and Audit Committee (PAC):

2.1 Notes the content and findings of the Internal Audit Review of Finance attached as Appendix 1 to this report.

2.2 Notes and agrees the action plan associated with the report as the management response to the findings.

2.3 Instructs the Chief Finance Officer to report progress in delivering the actions set out in the action plan through the Governance Action Plan presented to each Performance and Audit Committee meeting.

3.0 FINANCIAL IMPLICATIONS

3.1 None.

4.0 MAIN TEXT

4.1 Dundee Integration Joint Boards Internal Audit Plan 2020/21 set out a number of reviews to be delivered by the combined Internal Audit resources of Dundee City Council and FTF Audit and Management Services under the direction of the IJB’s Chief Internal Auditor. These reviews were identified following a review of the IJB’s Strategic Risk Register and are designed to support development of governance arrangements to mitigate against these risks.

4.2 The Internal Audit Review of Finance reviewed 2 risks contained in the Dundee Health and Social Care Partnership (DH&SCP) / IJB High-Level Risk Register which impact on the continuing delivery of the service and the ability to meet its aims as outlined within the Strategic and Commissioning Plan, and the arrangements to control and mitigate these risks - Risks 1, ‘Restrictions on Public Sector Funding’ and 2, ‘Unable to maintain IJB spend’, and specifically:

- Reviewed the arrangements in place for the delivery of the recommendations arising from the Ministerial Strategic Group (MSG) Self-Evaluation for the review of progress with integration of Health and Social Care as it relates to financial planning and management.

- Reviewed the recommendations arising from the Audit Scotland IJB Annual Audit Reports for 2017/18 and 2018/19 to determine the progress made in completing the recommendations made as they relate to financial planning and management. 4.3 In order to assess this position the Internal Audit work has:

- reviewed the recommendations and actions arising from MSG self evaluation, 2019/20 Annual External Audit Report, 2019/20 Annual Internal Audit Report, Governance Action Plan, and IJB Meeting Minutes;

- reviewed interdependencies and interfaces with Dundee City Council and NHS Tayside;

- considered working arrangements and reporting requirements for the above.

4.4 The review has identified a number of key findings and recommendations to be considered in relation to the governance arrangements surrounding the IJB and the complexities of its interface with the partner bodies. The Internal Auditors opinion is that that the review demonstrated Limited Assurance. This means that improvement is required to the system of governance, risk management and control to effectively manage risks to the achievement of objectives in the area audited.

4.5 These findings have been presented to the management of Dundee Health and Social Care Partnership who have agreed a range of actions in response to the key findings and recommendations. These actions are set out in the Action Plan on page 5 onwards of the Internal Audit Report. The progress of these actions will be monitored through the Governance Action Plan presented to each meeting of the Performance and Audit Committee.

5.0 POLICY IMPLICATIONS

5.1 This report has been screened for any policy implications in respect of Equality Impact Assessment. There are no major issues.

6.0 RISK ASSESSMENT

6.1 This report has not been subject to a risk assessment as it a status update and does not require any policy or financial decisions at this time.

7.0 CONSULTATIONS

7.1 The Chief Officer, Chief Internal Auditor and the Clerk were consulted in the preparation of this report.

8.0 BACKGROUND PAPERS

8.1 None.

Dave Berry Chief Finance Officer

Date: 3 February 2021 Dundee IJB Finance Report No. D05/19

Issued To: Dundee IJB Officers V Irons, Chief Officer D Berry, Chief Finance Officer

NHS Tayside Officers S Lyall, Director of Finance

Dundee City Council Officers D McCulloch, Head of Health and Community Care G Colgan, Chief Executive, Dundee City Council S Flight, Head of Corporate Finance

Performance & Audit Committee External Audit P Redpath, Senior Manager- Internal Audit, DCC

## Contents

| Section | Page | |---------|------| | Section 1 | Executive Summary | 2 | | Section 2 | Issues and Actions | 5 | | Section 3 | Detailed Findings\\Information | 8 | | Section 4 | Definitions of Assurance & Recommendation Priorities | 11 |

| Event | Date | |-------|------| | Draft Report Issued | 7 December 2020 | | Management Responses Received | 8 January 2021 | | Target Audit & Risk Committee Date | 3 February 2021 | | Final Report Issued | 18 January 2021 | CONTEXT AND SCOPE

1. Dundee IJB is required under sections 18 and 22 of the Public Bodies (Joint Working) Scotland Act to direct the resources it receives from the Local Authority and Health Board in line with its Strategic Plan. On an annual basis, Dundee IJB has to reach a budget settlement with both Dundee City Council and NHS Tayside regarding resources that will be devolved to the IJB to support delivery of local Health and Adult Social Care Services.

2. The formal process for agreeing the budget settlements is set out in the Integration Scheme. The budget settlement is derived from a series of discussions with partners, once Scottish Government budget information is available. Information regarding the 2019/20 budget initially became available in December 2018 but was refined in February 2019 as the Government reached agreement regarding its final 2019/20 budget.

3. Information for the 2020/21 budget became available from the Scottish Government in January 2020, following the General Election in December 2019. Both the Council and NHS Tayside were also developing their budgets at the same time and implications from both organisations’ budgets were considered as part of the arrangements for finalising the 2020/21 budget.

4. The Dundee Health and Social Care Partnership (DH&SCP) / IJB High-Level Risk Register contains 2 risks which impact on the continuing delivery of the service and the ability to meet its aims as outlined within the Strategic and Commissioning Plan. The first risk relates to Restrictions on Public Sector Funding and reflects that continuing restrictions on public sector funding will impact on Local Authority and NHS budget settlements in the medium term. The second risk relates to the inability to maintain the IJB spend within allocated resources.

5. Our audit reviewed the arrangements established to control and mitigate Risks 1, ‘Restrictions on Public Sector Funding’ and 2, ‘Unable to maintain IJB spend’, from the high-level risk register and specifically:

   - Reviewed the arrangements in place for the delivery of the recommendations arising from the Ministerial Strategic Group (MSG) Self-Evaluation for the review of progress with integration of Health and Social Care as it relates to financial planning and management.
   - Reviewed the recommendations arising from the Audit Scotland IJB Annual Audit Reports for 2017/18 and 2018/19 to determine the progress made in completing the recommendations made as they relate to financial planning and management.

AUDIT OPINION

6. The Audit Opinion of the level of assurance is as follows:

| Level of Assurance | System Adequacy | Controls | |--------------------|-----------------|----------| | Limited Assurance | Significant gaps, weaknesses or non-compliance were identified. Improvement is required to the system of governance, risk management and control to effectively | Controls are applied but with some significant lapses. | A description of all definitions of assurance and assessment of risks are given in Section 4 of this report.

07. The 2019/20 Annual Internal Audit Report stated that: ‘A high proportion of issues previously highlighted by ourselves and others which have resulted in agreed recommendations have not been taken forward as expected. Whilst Covid19 may have had some impact, it is not, in our view, the primary cause of the failure to deliver these key changes. We have also reported a number of areas where update reports were promised but not delivered.’ Our findings in this audit re-iterate the same issues.

08. A number of actions arising from previous external audit reports remain outstanding and have now been incorporated in the 2019/20 Annual External Audit Report. Those actions carried forward echo the themes raised in previous Annual Internal Audit Reports as well as improvement actions agreed as part of the MSG self evaluation.

09. In response to the recommendation arising from the Annual Internal Audit Report 2019/20 on the non-delivery of a high proportion of actions agreed with Internal Audit and others, the Chief Finance Officer presented the Governance Action Plan Update report to the full IJB in October 2020, and included additional information on remedial actions required, revised completion dates as well as setting out initiatives required to allow progress.

10. However, actions arising from the MSG improvement plan were not included in this process.

11. Following the presentation of an action plan in response to the Transformation & Service Redesign Internal Audit report to the PAC in May 2019, the May PAC ‘instructed the Chief Finance Officer to provide an update on the Action Plan to the meeting of the Committee to be held in September 2019’. However, this update was not provided, nor were the actions added to the Governance Action Plan and because there is no process to review agreed actions at the next meeting of a group, this oversight was not noticed. This echoes a finding from our 2017/18 Annual Internal Audit Report in relation to the lack of action point updates to the next meeting.

12. The risks highlighted in the IJB High-Level Risk Register in relation to Finance have been mitigated in part by the actions completed to date following the MSG Self-Evaluation and the completion of actions raised by Audit Scotland. In addition, the enhanced communication channels between the partners and the IJB have improved the approach to agreeing financial planning and management matters. However, the controls noted against the strategic financial risks have not been updated. We would recommend that as part of the next risk review, action taken in response to MSG and external audit recommendations should be incorporated into controls and reflected within risk scores.

13. Detailed findings/information is included at Section 3.

**ACTION**

14. The action plan at Section 2 of this report has been agreed with management to address the identified weaknesses. A follow-up of implementation of the agreed actions will be undertaken in accordance with the audit reporting protocol. ACKNOWLEDGEMENT

15. We would like to thank all members of staff for the help and co-operation received during the course of the audit.

A Gaskin, BSc. ACA Chief Internal Auditor

### Action Point Reference 1

**Finding:**

Internal Audit has reviewed progress against the actions arising from the Ministerial Strategic Group (MSG) Self-Evaluation for the review of progress with integration of Health and Social Care within the Integrated Finances and Financial Planning section. Whilst some progress has been made, a number of actions remain outstanding and neither the PAC nor the IJB have been updated on the current position or the impact of Covid19 on future ability to deliver the agreed actions.

A number of actions arising from previous external audit reports remain outstanding and have now been incorporated in the 2019/20 Annual External Audit Report. Those actions carried forward echo the themes raised in previous Annual Internal Audit Reports as well as improvement actions agreed as part of the MSG self evaluation.

In response to the recommendation arising from the Annual Internal Audit Report 2019/20 on the non-delivery of a high proportion of actions agreed with Internal Audit and others, the Chief Finance Officer presented the Governance Action Plan Update report to the full IJB in October 2020, and included additional information on remedial actions required, revised completion dates as well as setting out initiatives required to allow progress.

However, actions arising from the MSG improvement plan are not included in this process.

### Audit Recommendation:

Given the multiplicity of potentially overlapping audit and MSG recommendations and the impact of Covid19, we recommend that the actions be combined into a holistic action plan, reprioritised in light of changes to management capacity and risk. Internal Audit have recently written a template for this purpose which could be adapted for use by the IJB.

This action plan should be approved and monitored by the PAC and any non-delivery escalated to the IJB Board and/or Risk Register as required.

### Assessment of Risk:

- **Significant**
  - Weaknesses in control or design in some areas of established controls.
  - Requires action to avoid exposure to significant risks in achieving the objectives for area under review.

### Management Response/Action:

The weaknesses identified have largely been reported previously. The template prepared by Internal Audit noted above will be used to reprioritise and focus on remaining significant actions outstanding.

| Action by: | Date of expected completion: | |---------------------|------------------------------| | Chief Finance Officer | 31 March 2021 |

### Action Point Reference 2

**Finding:**

Following the presentation of an action plan in response to the Transformation & Service Redesign Internal Audit report to the PAC in May 2019, the minutes of the PAC in May 2019 show that the PAC ‘instructed the Chief Finance Officer to provide an update on the Action Plan to the meeting of the Committee to be held in September 2019’; which was not provided. However, there is no process to review agreed actions at the next meeting of a group so this oversight was not noticed.

This echoes a finding from our 2017/18 Annual Internal Audit Report in relation to the lack of action point updates to the next meeting.

**Audit Recommendation:**

a) As previously recommended and in line with other required changes to the minuting of meetings, which is now being taken forward, we would recommend again, that actions are clearly identified, properly recorded and an update provided to each meeting of the IJB and PAC.

b) Actions arising from the Transformation & Service Redesign internal audit report should continue to be monitored by being added to the Governance Action plan and their current status reported to the PAC.

**Assessment of Risk:**

Moderate

Weaknesses in design or implementation of controls which contribute to risk mitigation.

Requires action to avoid exposure to moderate risks to achieving the objectives for area under review.

**Management Response/Action:**

a) Clerk to the Board currently records a range of actions from each meeting however consideration by the IJB and PAC is required as to whether these should become formal items on each agenda.

b) This was an oversight and will be reviewed accordingly.

| Action by: | Date of expected completion: | |---------------------------------|-----------------------------| | Chief Finance Officer / Clerk to the Board | 31 March 2021 |

### Action Point Reference 3

**Finding:**

The risks highlighted in the IJB High-Level Risk Register in relation to Finance have been mitigated in part by the actions completed to date following the MSG Self-Evaluation and the completion of actions raised by Audit Scotland. In addition, the enhanced communication channels between the partners and the IJB have improved the approach to agreeing financial planning and management matters. However, the controls noted against the strategic financial risks have not been updated.

**Audit Recommendation:**

As part of the necessary update of these risks to reflect the impact of Covid19 and other external factors, actions taken in response to MSG and external audit recommendations should be incorporated into controls and reflected within risk scores.

**Assessment of Risk:**

| Level | Description | |-------|-------------| | Moderate | Weaknesses in design or implementation of controls which contribute to risk mitigation. Requires action to avoid exposure to moderate risks to achieving the objectives for area under review. |

**Management Response/Action:**

Relevant risk controls to be amended accordingly.

| Action by: | Date of expected completion: | |------------|-----------------------------| | Chief Finance Officer | 31 March 2021 | Follow Up of Financial Planning & management recommendations arising from MSG Improvement actions and Audit Scotland external audit reports

16. The 2019/20 Annual Internal Audit Report stated that: ‘A high proportion of issues previously highlighted by ourselves and others which have resulted in agreed recommendations have not been taken forward as expected. Whilst Covid19 may have had some impact, it is not, in our view, the primary cause of the failure to deliver these key changes. We have also reported a number of areas where update reports were promised but not delivered.’ Our findings in this audit re-iterate these issues.

17. The initial MSG Self-Evaluation report submitted to Dundee IJB in June 2019 indicated that progress on implementing the improvement actions identified through the MSG Self-Evaluation process would be submitted to Dundee IJB by 19 December 2019. This did not occur and, to date, no update has been provided to Dundee IJB.

18. A similar report incorporating the self-assessments for Dundee, Perth and Kinross and Angus IJBs was submitted to NHS Tayside in June 2019 and a progress report incorporating an update from each of the local Health and Social Care Partnerships was subsequently reported to the NHS Tayside Board in December 2019.

19. Integrated Finances and Financial Planning is one of the key sections of the MSG Self-Evaluation report and incorporates 6 sub-sections relating to actions required for improvement and best practice.

20. Internal Audit has reviewed progress against the actions within the Integrated Finances and Financial Planning section for Dundee IJB. Whilst some progress has been made against the Finance recommendations in the MSG report, a number of actions remain outstanding and neither the PAC nor the IJB have been updated on the current position or the impact of Covid19 on future ability to deliver the agreed actions.

21. The following points were noted:

- There are now regular meetings between senior finance officers of NHS Tayside, Dundee City Council and DH&SCP to discuss financial implications and pressures of the arrangements between the parties and wider financial planning.

- The NHS Tayside budget, which feeds into the budget for DH&SCP was approved in April 2020. Regular discussions and development sessions have been held between NHS Tayside, Dundee IJB and Dundee City Council to provide indications of the budget uplifts / savings required as part of the budget development / budget setting arrangements.

- Work is continuing to establish financial planning on a whole systems basis. A long-term financial plan / strategy for the IJB is being developed, but its completion and reporting to committee has been delayed and will need to be fundamentally revised to take account of the impact of Covid19.

- Arrangements for clarifying the value of large hospital set aside budgets to Dundee IJB is continuing. As part of the budget settlement for 2020/21 a further £1million in addition to the 3% uplift was allocated from NHS Tayside to Dundee IJB in relation to large hospital set aside.

- Work is still ongoing to streamline and strengthen the financial resources available to the Dundee IJB. A Partnership Finance Manager, in the same manner as Angus and Perth and Kinross IJB’s has been appointed following a recent recruitment exercise and took up the post in December 2020. Some staff who currently report to NHS Tayside’s Director of Finance will report to the Chief Financial Officer. Specific reports / reporting lines for the IJB will change in the same manner. Funding will be provided by NHS Tayside for this post. Work is also ongoing to transfer reporting responsibilities from NHS Tayside to the Chief Financial Officer and will be implemented when the Depute Chief Financial Officer takes up the post. At present there has been no transfer of Local Authority staff.

- Actions arising from internal audit D06/17-Workforce were referenced as actions on the MSG Improvement Plan. A number of these actions are still outstanding. The last update on progress towards completion of these actions was reported to the IJB PAC in November 2020, with a revised due date noted as March 2021.

22. One of the proposed improvement actions arising from the MSG Self-Evaluation related to “continuing to improve the contents of Directions in relation to financial implications”. The initial self-evaluation identified that “the use of the budget is reflected in directions from the IJB to the Council and Health Board, however we recognise that there is further work to do to develop our practice in this regard and include more detailed financial information in directions.” As noted in the 2019/20 Annual Internal Audit Report, new Scottish Government guidance on directions issued in January 2020 have not yet been presented and discussed at governance level.

23. Internal Audit have identified instances where a clearer use could have been made of directions and, as in previous years, note that directions are very high level and do not provide the detail now expected.

24. The discussions referred to in the first bullet at paragraph 21 above have been taken forward to assist in improving the support arrangements for the IJB from both Dundee City Council and NHS Tayside. An update to the Governance Action Plan in October 2020 highlights that “Progress is being made in strengthening the support structure and realigning priorities to ensure that actions are completed.”

Audit Scotland Annual Report

25. We also followed up actions arising from previous Audit Scotland Annual External Audit Reports as part of the audit fieldwork and the following points were noted:

26. Progress has been made or is now incorporated in the 2019/20 Annual External Audit Report. Those actions carried forward echo the themes raised in previous Annual Internal Audit Reports as well as improvement actions agreed as part of the MSG self evaluation. In addition, outstanding actions are complex ones such as long-term financial planning and linking performance reporting with financial monitoring.

Audit Follow Up process

27. The 2019/20 Annual Internal Audit Report stated that: ‘A high proportion of issues previously highlighted by ourselves and others which have resulted in agreed recommendations have not been taken forward as expected. Whilst Covid19 may have had some impact, it is not, in our view, the primary cause of the failure to deliver these key changes. We have also reported a number of areas where update reports were promised but not delivered.’ Our findings in this audit re-iterate the same issues.

28. A Governance Action Plan covering actions agreed through previous internal reports (including Annual Internal Audit Reports) as well as external audit recommendations was developed and first presented to the PAC in March 2019. As part of our testing of progress towards implementing the audit recommendations contained in the Transformation and Service Redesign report, we noted that although an action plan was provided to the PAC in May 2019, no progress updates on individual actions have been provided since, nor were the actions added to the Governance Action Plan.

29. Following the presentation of an action plan in response to the Transformation & Service Redesign internal audit report to the PAC in May 2019, the May PAC ‘instructed the Chief Finance Officer to provide an update on the Action Plan to the meeting of the Committee to be held in September 2019’.

30. However, this update was not provided and because there is no process to review agreed actions at the next meeting of a group, this oversight was not noticed.

31. Whilst our follow up work shows that some progress has been made with actions arising from this audit, and some actions are now no longer relevant due to the responsibilities for this area transferring to another group, weaknesses previously reported by Internal Audit in relation to minutes and action points remain, with the consequence that the process for monitoring whether action is taken as agreed is not robust.

32. Further development of the IJB and PAC minutes and papers to ensure full transparency and accurate recording of the discussions, questions asked and assurances provided has been considered. The update within the Governance Action Plan to the November 2019 meeting of the IJB highlights that “Minutes expanded as required to reflect key discussions”. However, from review of minutes for 2019/20 IJB meetings there is no evidence of questions being recorded, additional discussions and assurances provided over and above the commentary in the report. However, the 24 November PAC meeting was informed that minutes would improve from January onwards.

### Strategic Finance risks

33. The risks highlighted in the IJB High-Level Risk Register in relation to Finance have been mitigated in part by the actions completed to date following the MSG Self-Evaluation and the completion of actions raised by Audit Scotland. In addition, the enhanced communication channels between the partners and the IJB have improved the approach to agreeing financial planning and management matters. However, the controls noted against the strategic financial risks have not been updated. We would recommend that as part of the next risk review, action taken in response to MSG and external audit recommendations is considered as controls as well as the impact on risk scores.

34. An update to the High-Level Risk Register was submitted to the IJB at its meeting in August 2020. This paper references the actions arising from internal audit report D04/18 Risk Maturity assessment and sets out the work being undertaken by the Tayside Risk Management Group Risk Managers in Dundee, Angus and Perth Health and Social Care Partnerships, NHS Tayside and Dundee City Council. We therefore make no further recommendations in relation to risk management processes. **Definition of Assurance**

To assist management in assessing the overall opinion of the area under review, we have assessed the system adequacy and control application, and categorised the opinion based on the following criteria:

| Level of Assurance | System Adequacy | Controls | |--------------------|-----------------|----------| | **Substantial Assurance** | A sound system of governance, risk management and control exists, with internal controls operating effectively and being consistently applied to support the achievement of objectives in the area audited. | Controls are applied continuously or with only minor lapses. | | **Reasonable Assurance** | There is a generally sound system of governance, risk management and control in place. Some issues, non-compliance or scope for improvement were identified which may put at risk the achievement of objectives in the area audited. | Controls are applied frequently but with evidence of non-compliance. | | **Limited Assurance** | Significant gaps, weaknesses or non-compliance were identified. Improvement is required to the system of governance, risk management and control to effectively manage risks to the achievement of objectives in the area audited. | Controls are applied but with some significant lapses. | | **No Assurance** | Immediate action is required to address fundamental gaps, weaknesses or non-compliance identified. The system of governance, risk management and control is inadequate to effectively manage risks to the achievement of objectives in the area audited. | Significant breakdown in the application of controls. | **Assessment of Risk**

To assist management in assessing each audit finding and recommendation, we have assessed the risk of each of the weaknesses identified and categorised each finding according to the following criteria:

| Category | Description | Action Required | |----------------|-----------------------------------------------------------------------------|------------------------------------------------------| | Fundamental | Non Compliance with key controls or evidence of material loss or error. | Action is imperative to ensure that the objectives for the area under review are met. | | Significant | Weaknesses in design or implementation of key controls i.e. those which individually reduce the risk scores. | Requires action to avoid exposure to significant risks to achieving the objectives for area under review. | | Moderate | Weaknesses in design or implementation of controls which contribute to risk mitigation. | Requires action to avoid exposure to moderate risks to achieving the objectives for area under review. | | Merits attention | There are generally areas of good practice. | Action may be advised to enhance control or improve operational efficiency. | 1.0 PURPOSE OF REPORT

1.1 This is presented to the Committee for:

- Assurance

This report relates to:

- Government policy/directive
- Legal requirement

This aligns to the following NHS Scotland quality ambition(s):

- Safe
- Effective
- Person Centred

This report is being brought to the Committee to provide assurance on the clinical and care governance activities and arrangements across the Partnership as outlined in the Getting It Right For Everyone (GIRFE) Framework in accordance with the Partnership integration scheme. Clinical Governance is a statutory requirement to report on, at Board level, from Scottish Government as per NHS MEL (1998) 75. The Performance and Audit Committee is being asked to provide their view on the level of assurance this report provides and therefore the level of assurance regards clinical and care governance within the Partnership. The timescale for the data within this report is from 1 October 2020 to 30 November 2020.

2.0 RECOMMENDATIONS

2.1 It is recommended that the Performance and Audit Committee (PAC):

- Note the Exception Report for the Dundee Health & Social Care Partnership Clinical, Care & Professional Governance Group as detailed in Section 4.

2.2 This report is being presented for:

- Assurance

As lead Officer for Dundee Health & Social Care Partnership (DHSCP) I would suggest that the level of assurance provided is: Moderate.

3.0 FINANCIAL IMPLICATIONS

3.1 None. 4.0 MAIN TEXT

4.1 Situation

4.1.1 This report is being brought to the Committee to provide assurance on the clinical and care governance activities and arrangements across the Partnership as outlined in the Getting It Right For Everyone Framework in accordance with the Partnership integration scheme. Clinical Governance is a statutory requirement to report on, at Board level, from Scottish Government as per NHS MEL (1998) 75. The Performance and Audit Committee is being asked to provide their view on the level of assurance this report provides and therefore the level of assurance regards clinical and care governance within the Partnership. The timescale for the data within this report is from 1 October 2020 to 30 November 2020.

As lead Officer for Dundee HSCP I would suggest that the level of assurance provided is: Moderate.

4.2 Background

4.2.1 The role of the Dundee Health & Social Care Partnership Governance group is to provide assurance to the Dundee Integration Joint Board, NHS Tayside Board (through the Care Governance Committee) and Dundee Council, that there are effective and embedded systems for Clinical, Care & Professional Governance in all services within Dundee Health and Social Care Partnership.

4.2.2 The Getting It Right For Everyone Framework has been agreed by all three Health & Social Care Partnerships and the recent refresh of the document was endorsed at Care Governance Committee. To ensure consistency of approach between Local Authorities, Tayside NHS Board and the IJBs for the three Health & Social Care Partnerships, quality assurance is assessed against an agreed, prioritised common data set for each of the governance domains as detailed below. A Getting It Right For Everyone Steering Group has been established and continues to meet, with representatives from each of the three Partnerships and part of its remit is to support additional common assurance measures and this template.

4.2.3 The six domains continue to evolve over time and must be adaptable and responsive to the changes in legislation and external support and monitoring. The domains reflect the principles set out in the Health and Social Care Standards, My support, My life; Scottish Government, 2018 and the Quality of Care Approach, Healthcare Improvement Scotland and Care Inspectorate, September 2018. The domains are:

| Information Governance | |------------------------| | Professional Regulation and Workforce Development | | Patient/Service User/Carer and Staff Safety | | Patient/Service User/Carer and Staff Experience | | Quality and Effectiveness of Care | | Promotion of Equality and Social Justice |

4.2.4 There is a clinical governance strategic risk for NHS Tayside Clinical Governance Risk 16. The current risk exposure rating of this risk considers the Clinical and Care Governance reporting arrangements within the Partnerships and reflects the complexity in moving towards integrated Clinical and Care Governance arrangements within each of the HSCPs. The Interim Evaluation of Internal Control Framework Report No T09/20 identifies the need for greater consistency in reporting of performance and quality by the HSCPs.

4.3 Assessment

4.3.1 Clinical and Care Risk Management

4.3.1.1 Risk management across Dundee HSCP continues to be recorded across both a Health (service risks) and Local Authority (strategic risks) system. While this in itself does not prevent appropriate risk management processes being undertaken it does increase the required administration to link together risks and ensure visibility and connections between strategic and service risks. There are ongoing discussions to determine the most effective route forwards for risk management systems. 4.3.1.2 Top 5 Risks in Dundee HSCP

| Title of Risk | Adequacy | Inherent Risk Score (without controls) | Current Risk Score (with current controls in place) | |------------------------------------------------------------------------------|-----------------------------------------------|----------------------------------------|-----------------------------------------------------| | 721 - Current funding insufficient to undertake the service redesign of the integrated substance misuse service | Inadequate - No evidence to support the effectiveness of controls | 20 | 20 | | 612 - Insufficient numbers of staff in integrated substance misuse service with prescribing competencies | Incomplete – Controls are appropriately designed but these are not consistently applied | 25 | 25 | | 233 - Increasing Patient demand in excess of resources | Incomplete - Controls are appropriately designed but these are not consistently applied | 15 | 25 | | 839 - COVID-19 Maintaining Safe Substance Misuse Service | Incomplete - Controls are appropriately designed but these are not consistently applied | 12 | 15 | | 729 - Nursing Workforce | Inadequate – No evidence to support the effectiveness of controls | 15 | 12 |

4.3.1.3 Risk 721: Risk that current funding would be insufficient to undertake redesign of the integrated substance misuse service.

The current risk rating is 20. Since the launch of the Drug Commission report in August 2019, ISMS has recruited five additional band 5 nurse posts, 3 new posts and 2 posts to replace previous fixed term positions. There is also a long term vacancy for a locality manager to lead strategic financial planning. Controls available to Integrated Substance Misuse Service (ISMS) have been applied and the risk exposure remains 20, which contributes to the risk ratings for Datix risks 612, 233, 839 and 458.

4.3.1.4 Risk 621: Insufficient numbers of ISMS staff with prescribing competencies.

The controls available to ISMS have been applied and the risk exposure remains 25. Proposed controls include the relevant Dundee Partnership Action Plan for Change actions and the implementation of national Medication Assisted Treatment standards, which have been added as Datix risk actions to enable DHSCP and NHST to monitor the consequences of these planned controls. The risk exposure with the planned/proposed controls remains 25 as the controls do not yet address the prescribing capacity issues for those established on opiate substitution treatment with multiple complex needs, the population with the highest fatality risk.

4.3.1.5 Risk 233: Increased patient demand in excess of resources.

Despite applying controls the risk rating has increased from 15 to 25. Proposed controls include the relevant Dundee Partnership Action Plan for Change actions and the implementation of national Medication Assisted Treatment standards, which have been added as Datix risk actions to enable DHSCP and NHST to monitor the consequences of these planned controls. The risk exposure of the planned/proposed controls remains 25 as the controls do not address the nurse key working capacity issues and the service continues to hold 240 cases that do not have a named nurse allocated to their care.

4.3.1.6 Risk 839: COVID-19 Maintaining safe substance use services.

Integrated Substance Misuse Service has rapidly adapted service provision to continue to deliver person-centred care during the COVID pandemic, working in partnership with other agencies. We have maintained provision of opiate substitution treatment and alcohol detox, despite a 50% increase in alcohol referrals compared to a similar period in 2019. The risk rating remains 15 as staffing levels can fluctuate and clinical activity has increased.

4.3.1.7 Risk 729: Nursing Workforce.

The nursing workforce continues to be under significant pressure across a number of teams. Risk 729 relates specifically to the inpatient team in the Medicine for the Elderly wards, a number of other nursing teams also have risks recorded.

The teams are working flexibly to ensure safe care is delivered using colleagues from across the Partnership to support where able. There is added strain in the system due to the requirement to support the COVID testing centre and the vaccination programme.

As lead Officer for Dundee HSCP I would suggest that the level of assurance provided is: Moderate.

4.3.2 Clinical & Care Governance Arrangements

4.3.2.1 Dundee HSCP has established processes for Clinical, Care and Professional Governance in order to ensure processes and scrutiny are of a level which can provide the required assurance. A number of elements of governance are working well across the Partnership with the development of the Primary Governance Groups becoming established and feeding in an enhanced quality of assurance to the CCPG Group.

4.3.2.2 The CCPG Group meets every two months and receives information as outlined in the table below. Operational managers present an exception report to each CCPG Group highlighting challenges, issues and exceptional pieces of work. An annual performance framework requests that each service present a comprehensive annual report on all aspects of clinical, care and professional governance.

Governance Reporting Table

| Primary Governance Group | CCPG Group | Care Governance Committee | |--------------------------|------------|--------------------------| | Scorecard | Full | Exceptions (from scorecard) | Persistent Exception (Three Reports) Exceptions affecting multiple teams Level of Risk (High) | | Datix Themes/Action Taken| All Service Reported and themed | Exceptions (Individual/Themes) | Persistent Exception (Three Reports) Exceptions Affecting Multiple Teams Level of Risk (High) | | Red Events | All for service | All | Overview – themes/numbers | | LAER/SAER/SCR | All reported and learning shared | High Level Summary | Exceptions Organisational Learning Organisational Risk | | Complaints (and SPSO) | All – learning shared | Report highlighting numbers/service areas/themes | SPSO Numbers Organisational Learning | | Risks | All for service | High Level Report with assurance statement. Persistent long term risks Transient risks | Overview Report Persistent Exception (Three Reports) Exceptions affecting multiple teams Level of Risk (High) | | Inspection Reports | Action Plan Produced per team (where applicable) | Action Plan Produced per team (where applicable) | Overview Statement | | Standards/Legislation/ Guidelines | New Standards Reported | Agenda items prioritised when required | Organisational Impact | The CCPG Forum has changed its format and is now a forum specifically for sharing of good practice and learning in relation to challenges and provides support and development to managers and lead governance staff across the Partnership. October’s forum reviewed exception reports from services and had focussed discussion on a number of operational challenges. The group then had an interaction session on the Datix Risk Management system via MS Teams.

As lead Officer for Dundee HSCP I would suggest that the level of assurance provided is: Moderate.

4.3.3 Adverse Event Management

4.3.3.1 The chart below shows the type of events reported through the NHS Tayside Adverse Event Management System (Datix) between 01/06/2019 and 30/11/2020. There was a total of 3330 events reported within the time period.

This chart shows an increase in adverse events without harm over the past 5 months. This will be explored further in this report when we separate the top 5 event categories below. The following graph shows the adverse events reported by impact from 01.06.2020 to 31.11.2020. 4.3.3.3 Top 5 Categories of Adverse Events

The following table shows the top five categories reported between 01.10.2020 to 31.11.2020 by service. The top five categories are Slip, Trip, Fall (inpatients only) (124 incidents); Violence and Aggression (104 incidents); Medication Adverse Event (33 incidents); Documentation/Administration (20 incidents); and Clinical Challenging Behaviour (17 incidents).

| TYPE OF EVENTS REPORTED OVER 2 MONTH PERIOD | Adults and Older People | Allied Health Professions | Area Psychological Therapy Service | Brain Injury Rehabilitation | Community Mental Health Services | ISMS | MFE (Medicine for the Elderly) | Other | Palliative Medicine | Psychiatry of Old Age | Total | |--------------------------------------------|-------------------------|---------------------------|-----------------------------------|-----------------------------|---------------------------------|------|-----------------------------|-------|---------------------|---------------------|-------| | SLIP, TRIP or FALL (in-patients only) | 1 | 3 | 0 | 8 | 1 | 0 | 40 | 0 | 5 | 66 | 124 | | VIOLENCE & AGGRESSION | 7 | 2 | 0 | 0 | 2 | 8 | 6 | 2 | 1 | 76 | 104 | | MEDICATION ADVERSE EVENT | 14 | 0 | 0 | 1 | 0 | 4 | 4 | 0 | 5 | 5 | 33 | | DOCUMENTATION/ADMINISTRATION | 3 | 2 | 1 | 1 | 3 | 6 | 0 | 3 | 1 | 0 | 20 | | CLINICAL CHALLENGING BEHAVIOUR | 1 | 1 | 0 | 0 | 0 | 1 | 3 | 0 | 0 | 11 | 17 | | Total | 26 | 8 | 1 | 10 | 6 | 19 | 53 | 5 | 12 | 158 | 298 | 4.3.3.4 The following graph shows the monthly number of events by severity for Slips, Trips and Falls (In-Patient only).

![Graph showing monthly number of events by severity for Slips, Trips and Falls (In-Patient only).]

4.3.3.5 Of the 124 events, the majority (106) were across Older Peoples Services; 66 of these in Psychiatry of Old Age and 40 in Medicine for the Elderly. Work has commenced across both of these areas to explore the number of slips, trips and falls reported with the Patient Safety Team.

4.3.3.6 The clinical teams have noted that patients appear to be more frail, potentially due to the impact of COVID-19, and require significantly more rehabilitation, over a longer period of time to return them to levels of functional independence.

4.3.3.7 The number of incidents has increased over the time period and this will be continue to be monitored. Incidents with harm continue to be reviewed and in this reporting period there were only two incidents that were graded as moderate, with no incidents graded as major or extreme. The harm caused is predominantly bruising or grazing, although it should also be noted that a patient also chipped a tooth within this reporting period. 4.3.3.8 The following graph shows the monthly number of events for violence and aggression.

4.3.3.9 During this reporting period there has been a significant spike in October followed by a resultant fall in November. Analysis of these events shows that:

- 4 people were repeatedly involved in 56 events.
- 7 people were named in 2-5 events
- 9 people were named in only one event

A number of these patients have been discharged into November explaining the resultant fall in events.

4.3.3.10 Of the 104 incidents reported during this reporting period 76 of these were located in Psychiatry of Old Age Wards. 26 Of these were reported as incidents with harm. A review of these incidents identifies a significant percentage showing harm to staff via pinching, punching or kicking, although there is no serious or lasting effect from this harm.

4.3.3.11 The team have noted that the patient group have become younger and fitter over the past 12 months or so and this has necessitated the requirement for enhanced levels of training for staff to better support this patient group. This training has been focussed on wards 3 and 4 at Kingsway Care Centre as the vast majority of incidents are reported here (95%). 4.3.3.12 The following graph shows the monthly number of medication adverse events.

![Medication Adverse Events reported by Event Severity June 2019 onwards](image)

4.3.3.13 Medication adverse events are spread out over a number of different clinical teams, that is to say there is no particular theme or area of concern within one team. This, however, is closely monitored and any emerging areas of concern are discussed at the CCPG Group.

During this reporting period there were no incidents with harm reported. 4.3.3.14 The following graph shows the monthly number of documentation/administration adverse events.

![Graph showing monthly documentation/administration adverse events from June 2019 to November 2020.]

4.3.3.15 There are a range of incidents reported through documentation/administration which include breach of confidentiality, documentation error and delays reporting beyond standard targets. The delays reporting beyond standard targets relate to staff having to work additional hours to complete documentation. Staff have been reminded that this does not constitute an adverse event and therefore does not need to be reported within the Datix system.

4.3.3.16 Where breaches of confidentiality occur there is close working with the information governance team to ensure that all necessary steps have been taken to comply with GDPR regulations and also professional duty of candour. There are no single areas of concern in relation to these events and this will continue to be monitored. 4.3.3.17 The following graph shows the monthly number of clinically challenging behaviour events.

4.3.3.18 These events are predominantly recorded in the Psychiatry of Old Age service. There is a positive reporting culture within this service and the team report being able to effectively manage the clinically challenging behaviours well.

4.3.3.19 The increase in minor incidents appears to correlate with the increase in violence and aggression events, and, as mentioned earlier the patient group are becoming younger and fitter which has led to the team receiving additional training to best manage the changing demographic of this patient group. 4.3.3.20 Number of Overdue Verified Adverse Events

This table shows a significant improvement in the number of overdue verified adverse events. It is recognised that the figures remain high and further work is required to continue with the demonstrated improvement. Additional staff have been recruited to support this work and training continues to ensure growing capacity to further reduce and maintain the positive work seen over the past three months.

As lead Officer for Dundee HSCP I would suggest that the level of assurance provided is: Moderate

4.3.4 Pressure Ulcers

4.3.4.1 Pressure Ulcer numbers remain low across the Partnership. Reviews are completed in relation to all pressure ulcers that are recorded and from these assurance is provided that all preventable steps are taken in relation to pressure ulcer care.

4.3.4.2 The main theme apparent is pressure ulcers developing within the community setting and reviews have demonstrated that patients often do not wish to follow the advice provided by the community nursing service. Challenges also remain in relation to associated skin care bundles and there is ongoing improvement work in place. 4.3.4.3 Pressure Ulcer Incidents by Grade from June 2019

4.3.4.4 Pressure Ulcer Incidents by subcategory from June 2019

As lead Officer for Dundee HSCP I would suggest that the level of assurance provided is: Moderate 4.3.5 Complaints

4.3.5.1 Stage 1 NHS Complaints

| Directorate | Days_Band | Total | 5-9 Days | 10-14 Days | |-------------|-----------|-------|----------|------------| | Total | | 4 | 2 | 2 | | Dundee HSCP (Health and Social Care Partnership) | | 4 | 2 | 2 |

There are currently four stage 1 complaints being managed.

4.3.5.2 Stage 2 NHS Complaints

| Speciality | Days_Band | Total | 5-9 Days | 10-14 Days | 15-20 Days | 21-25 Days | 26-30 Days | 31-35 Days | 36-40 Days | 40+ Days | |------------|-----------|-------|----------|------------|------------|------------|------------|------------|------------|----------| | Total | | 27 | 2 | 5 | 3 | 3 | 2 | 2 | 2 | 8 | | MISSING | | 3 | 1 | 2 | - | - | - | - | - | - | | Adult Psychotherapy Service | | 3 | - | - | 1 | 1 | - | 1 | - | - | | General Practice | | 3 | 1 | 1 | - | - | - | - | - | 1 | | Physiotherapy | | 1 | - | - | 1 | - | - | - | - | - | | Community Mental Health Services | | 11 | - | 2 | 2 | 2 | 1 | 1 | - | 3 | | Eating Disorder Service | | 1 | - | - | - | - | - | - | 1 | - | | MFE (Medicine for the Elderly) | | 4 | - | - | - | - | 1 | - | - | 3 | | Tayside Sexual and Reproductive Health | | 1 | - | - | - | - | - | - | - | 1 |

This table shows the number of open complaints and how long they have been active. The complex nature of some of these complaints account for the length of time it is taking to resolve them.

4.3.5.3 Total Number of Complaints (NHS) 2019-2020 (to November) 4.3.5.4 The complaints for 2020 have been generally lower than 2019 through to September. 2019 saw a gradual reduction in the number of complaints over the last 6 months, while 2020 is showing a gradual increase. While, in part, this may be due to a reduction in complaints due to COVID, the overall number of complaints from September is higher for 2020 when compared to 2019.

4.3.5.5 Top Themes Recorded:

The top three themes within Health were once again, for the fourth quarter running, Attitude and Behaviour; Clinical Treatment and Communication (Oral). The top two sub themes were Disagreement with treatment/care plan and Lack of support.

4.3.5.6 Staff have been encouraged to undertake training in relation to complaints management using the Power of Apology Sessions.

4.3.5.7 A more coordinated response is being developed linking the outcomes of complaints to services, across the Partnership, to support and encourage the sharing of learning amongst all teams.

As lead Officer for Dundee HSCP I would suggest that the level of assurance provided is: Moderate

4.3.6 External Reports & Inspections

4.3.6.1 Healthcare Improvement Scotland Inspection for the Royal Victoria site in July was in relation to Care of Older People:

The recommendations were in relation to:

- Documentation of reassessment of MUST and oral health on transfer
- MUST screening assessment tool is completed in full
- Ensure oral hygiene assessment is completed.
- Develop person centred care planning.
- Review documentation to ensure person centred care plan can be recorded.
- Review SKIN bundle to ensure documentation captures key elements of pressure ulcer prevention, monitoring and management.
- All staff must ensure appropriate hand hygiene practice.
- Ensure environment is effectively monitored and maintained to ensure infection prevention and control practice.

4.3.6.2 Seventeen actions have been identified and incorporated into the action plan. Ten actions are now complete. Timeframes have been adjusted to allow time for development and subsequent audit of documentation to be undertaken in relation to outstanding actions. The impact of COVID has also impacted on achievement of some actions. All actions should be complete by May 2021.

As lead Officer for Dundee HSCP I would suggest that the level of assurance provided is: Moderate

4.3.7 Adult Support & Protection

4.3.7.1 The following tables provide information relating to the trend activity carried out under Adult Support and Protection Legislation. There was a significant reduction in the numbers of concerns raised across all protection matters during the first four months of the pandemic. As lockdown eased there was an increase in referrals with numbers rising above that of pre-COVID. It should be noted that despite the increase, the numbers of cases progressing from concern to formal action remained within the normal parameters. These numbers are now returning to pre-COVID rates. 4.3.7.2 Police Scotland remains the highest referring agency. Information shows that referrals are often for welfare concerns and these are screened and, a duty to enquire progressed and actioned in the appropriate way. As a result, a low rate of original concerns progress to an Adult Support and Protection investigation. See table below.

| Thu - Wed commencing | ASP Concern | Onwards | NFA /In Progress | ASP Duty to Inquire | Onwards | NFA /In Progress | ASP Investigation | ASP Case Conference | ASP Review Case Conference | ASP Core Group/ Protection Plan Meetings | |----------------------|-------------|---------|------------------|---------------------|---------|------------------|-------------------|---------------------|--------------------------|------------------------------------------| | 10-Sep-20 | 39 | 33 | 6 | 35 | 2 | 33 | 1 | - | - | - | | 17-Sep-20 | 55 | 44 | 11 | 43 | 3 | 40 | 1 | - | - | 1 | | 24-Sep-20 | 52 | 41 | 11 | 36 | 4 | 32 | 2 | 1 | 4 | - | | 01-Oct-20 | 50 | 40 | 10 | 43 | 6 | 37 | - | 2 | - | - | | 08-Oct-20 | 34 | 28 | 6 | 27 | 3 | 24 | 1 | 1 | 2 | - | | 15-Oct-20 | 41 | 37 | 4 | 36 | 2 | 34 | 3 | 3 | 2 | - | | 22-Oct-20 | 60 | 49 | 11 | 48 | 3 | 45 | - | - | 2 | - | | 29-Oct-20 | 42 | 38 | 4 | 45 | - | 45 | 1 | 1 | - | - | | 05-Nov-20 | 46 | 39 | 7 | 35 | 4 | 31 | 1 | 1 | - | 1 | | 12-Nov-20 | 43 | 32 | 10 | 32 | 4 | 28 | 2 | - | 1 | - | | 19-Nov-20 | 51 | 42 | 9 | 45 | 4 | 41 | 2 | 2 | 1 | - | | 26-Nov-20 | 44 | 37 | 6 | 41 | 2 | 39 | - | 2 | - | 1 | | 03-Dec-20 | 49 | 41 | 8 | 41 | 6 | 35 | 2 | 1 | 1 | 2 | 4.3.7.3 The following table provides an indication of the types of concern raised through referrals for the period (Thursday-Wednesday commencing 3 December 2020). During the pandemic, regular reporting has been submitted nationally showing the impact and actions taken to ensure protection matters continue to be addressed. This report is also considered at the relevant protection committees including the Dundee Adult Support Protection Committee and the Dundee Chief Officers Group.

**Breakdown of Principle Type of Concern**

Thu - Wed commencing: 03-Dec-20

| Type of Concern | Count | |-----------------------------------------|-------| | Welfare Concerns - Older People | 6 | | Welfare Concerns - Adults | 22 | | Suicide Ideation | 4 | | Financial Harm | 1 | | Physical harm | - | | Actual self harm | 4 | | Fire safety risk | 3 | | Sexual harm | 1 | | Domestic abuse | 1 | | Self neglect | 1 | | Threat of self harm | 1 | | Suicide Attempt | 2 | | Harassment | 1 | | Discrimination | - | | Emotional/Psychological harm | - | | Neglect by carer | 1 | | Exploitation | - | | Other | 1 | | **Total** | **49**| Breakdown of Reasons for NFA at Duty to Inquire

| Reason | Count | |------------------------------------------------------------------------|-------| | Existing support services have been informed of the concern and will manage appropriately (Least restrictive approach) | 8 | | Conduct appropriate follow-up for community care needs (Social Work) | 1 | | NFA Required - Inappropriate Referral to ASP | 9 | | Advice and information given and signposted to appropriate services /support | 6 | | The adult is currently admitted to hospital for mental health assessment / treatment | 1 | | The adult has been admitted to hospital for medical treatment. Reported to the appropriate Social Work Team | 2 | | After initial inquiry by a Designated Council Officer the adult declined support | 1 | | Other | 1 | | Concern to be passed onto GP for information and support | 1 | | Risks remain and a Multi Agency Risk Management Meeting will be arranged | 2 | | Council Officer has inquired and appropriate safeguards have been put in place prior to investigation | - | | Adult Lives out with Dundee Area - Concern passed to Appropriate Local Authority | - | | Step in Progress | 9 | | **Total** | **41**|

As lead Officer for Dundee HSCP I would suggest that the level of assurance provided is: Moderate The level of assurance should be provided for each heading under assessment (2.3).

| Level of Assurance | System Adequacy | Controls | |--------------------|-----------------|----------| | Comprehensive Assurance | Robust framework of key controls ensures objectives are likely to be achieved. | Controls are applied continuously or with only minor lapses. | | Moderate Assurance | Adequate framework of key controls with minor weaknesses present. | Controls are applied frequently but with evidence of non-compliance. | | Limited Assurance | Satisfactory framework of key controls but with significant weaknesses evident which are likely to undermine the achievement of objectives. | Controls are applied but with some significant lapses. | | No Assurance | High risk of objectives not being achieved due to the absence of key internal controls. | Significant breakdown in the application of controls. |

4.4 Quality/Patient Care

The principle focus of all services is a desire to achieve the six dimensions of healthcare quality. These state that healthcare must be:

- Safe
- Effective
- Patient-centred
- Timely
- Efficient
- Equitable

The work being progressed will have a positive impact on the quality of care and services for staff and the population of Dundee and Tayside.

4.5 Workforce

The continuing impact of COVID-19 is being felt by staff across the HSCP as they continue to support service delivery alongside supporting COVID testing and the delivery of vaccinations. Dundee HSCP continues to support staff health and wellbeing throughout this challenging time.

Nursing and AHP teams, in particular, have faced significant challenge. This has led to the development of more Tayside wide collaborative working with colleagues from acute and the other HSCP's to support mitigation of these risks.

4.6 Financial

N/A.

4.7 Risk Assessment/Management

Risks are included in the report above.

4.8 Equality and Diversity, including Health Inequalities

An impact assessment has not been completed. Promotion of Equality and Social Justice is one of the domains included in the GIRFE reporting assurance framework. 4.9 Other Impacts

There are no other directs impacts of this report.

4.10 Communication, Involvement, Engagement and Consultation

The Dundee HSCP has carried out its duties to involve and engage external stakeholders where appropriate.

4.11 Route to the Meeting

This has been previously considered by the following groups as part of its development. The groups have either supported the content, or their feedback has informed the development of the content presented in this report.

- Dundee HSCP CCPG Group, 3 December 2020.

5.0 POLICY IMPLICATIONS

5.1 This report has been screened for any policy implications in respect of Equality Impact Assessment. There are no major issues.

6.0 RISK ASSESSMENT

| Risk 1 Description | The risk of not providing sufficient assurance through governance assurance routes will reduce confidence in the ability of the HSCP to deliver safe, quality care. | |--------------------|----------------------------------------------------------------------------------------------------------------------------------| | Risk Category | Governance | | Inherent Risk Level| Likelihood (2) x Impact (4) = Risk Scoring (8) | | Mitigating Actions (including timescales and resources) | Systems in place for all operational teams to provide exception reports to the clinical, care and professional governance group. ‘Getting It Right’ Group established to support development of reporting framework for HSCP. | | Residual Risk Level| Likelihood (2) x Impact (4) = Risk Scoring (8) | | Planned Risk Level | Likelihood (1) x Impact (3) = Risk Scoring (3) | | Approval recommendation | The risk level should be accepted with the expectation that the mitigating actions are taken forward. |

7.0 CONSULTATIONS

7.1 The Chief Finance Officer, Chief Officer, Locality Managers and the Clerk were consulted in the preparation of this report. 8.0 BACKGROUND PAPERS

8.1 None.

Dr. David Shaw Clinical Director

DATE: 8 January 2021

Diane McCulloch Chief Social Work Officer / Head of Health and Community Care

Report Author: Matthew Kendall, AHP Lead. 1.0 PURPOSE OF REPORT

1.1 The purpose of this report is to summarise the complaints performance for the Health and Social Care Partnership (HSCP) in the second quarter of 2020/21. The complaints include complaints handled using the Dundee Health and Social Care Partnership Social Work Complaint Handling Procedure, the NHS Complaint Procedure and the Dundee City Integration Joint Board Complaint Handling Procedure.

2.0 RECOMMENDATIONS

It is recommended that the Performance and Audit Committee (PAC):

2.1 Notes the content of the report.

2.2 Notes the complaints handling performance for health and social work complaints set out within this report.

2.3 Notes the work which has been undertaken to address outstanding complaints within the HSCP and to improve complaints handling, monitoring and reporting (sections 4.6 and 4.13).

3.0 FINANCIAL IMPLICATIONS

3.1 None.

4.0 MAIN TEXT

4.1 Since the 1st April 2017 both NHS and social work complaints follow the Scottish Public Service Ombudsman Model Complaint Handling Procedure. Both NHS Tayside Complaint Procedure and the Dundee Health and Social Care Partnerships Social Work Complaint Handling Procedures have been assessed as complying with the model complaint handling procedure by the Scottish Public Service Ombudsman.

4.2 Complaints are categorised by 2 stages: Stage 1: Frontline Resolution and Stage 2: Investigation. If a complainant remains dissatisfied with the outcome of a Stage 1: Frontline Resolution complaint, it can be escalated to a Stage 2. Complex complaints are handled as a Stage 2: Investigation complaint. If a complainant remains dissatisfied with the outcome of Stage 2: Investigation complaint they can contact the Scottish Public Services Ombudsman who will investigate the complaint, including professional decisions made. Complaints about the delivery of services are regularly presented to the Clinical, Care and Professional Governance Group to inform service improvement. 4.3 Social Work Complaints

In the second quarter of 2020/21 a total of nine complaints were received about social work or social care services in the Dundee Health and Social Care Partnership. This is higher than last quarter but still lower than this time last year.

Graph 1 - Number of Social Work complaints received quarterly

The graph shows that there has been a slight increase in the complaints received within Q2 compared to Q1.

4.4 Social Work complaints by reason for concern

Complaints about a delay in responding to enquiries and requests have dropped from 7 to 0 this quarter which is excellent considering we were working within a pandemic at home.

| Reason for Concern | Number | |--------------------------------------------------------|--------| | Attitude, behaviour or treatment by a member of staff | 0 | | Delay in responding to enquiries and requests | 2 | | Dissatisfaction with our policy | 2 | | Failure to provide a service | 1 | | Failure to follow the proper administrative process | 2 | | Failure to meet our service standards | 2 |

The numbers of social work complaints, while having a slight increase this quarter, are still relatively small. The complaints received were regarding several services and suggest no themes or patterns of dissatisfaction with services at this time.

4.5 Social Work Complaints Stages and Outcomes

Three complaints received were handled at a frontline resolution stage compared to five last quarter and this quarter we received six complaints at stage 2 investigation from the beginning compared to one last quarter. Of these, one stage 2 complaint is still open and under investigation, none were upheld, three were partially upheld with planned service improvements, a further two were not upheld and three were recorded as duplicate complaints.

| Stage | Number | |--------------------------------------------|--------| | Frontline Resolution | 3 | | Investigation (Escalated from Frontline) | 0 | | Investigation | 6 | | Joint with NHS | 0 | 4.6 Social Work Complaints Resolved Within Timescales

Seven of the Social Work complaints received by the Partnership were able to be resolved within the target dates. One missed the deadline minimally and the final one is currently still under investigation.

Graph 2 - % of Social Work Complaints resolved within timescales

The graph shows that there has been a sharp increase in the number of complaints that are resolved within timescales. The Customer Care and Governance Officer is ensuring that delays are kept to a minimum and processes are correctly followed. Meetings with Investigating Officers have unfortunately been delayed due to the pandemic. This quarter as you can see, we have had a real push on ensuring that the complaints are resolved within the timescales and we hope to keep this on throughout the remainder of the year.

4.7 Planned Service Improvements

The three partially upheld complaints have all identified a cause and have service improvements planned to address these.

4.8 Scottish Public Service Ombudsman Complaints

No complaints were referred to the SPSO this quarter.

4.9 NHS Complaints

In the second quarter of 2020/21 a total of 41 complaints were received about Dundee Health and Social Care Partnership health services compared to only 25 in quarter one. These are complaints which have been coded against DHSCP, there may be other complaints where DHSCP have contributed to a joint response: The graph shows that during quarter two there has been a sharp increase in complaints received, bringing us back up to a more expected level.

4.10 NHS Complaints by Theme

The top three themes were once again for the fourth quarter running Attitude and Behaviour; Clinical Treatment and Communication (Oral).

The top three sub themes were Disagreement with treatment/care plan, Staff Attitude and Lack of support for this quarter.

4.11 NHS Complaints Stages

11 complaints were handled at a frontline resolution stage compared to 20 last quarter. Of these complaints, four were upheld, three were partially upheld and two were not upheld.

This quarter saw six complaints handled as Stage 2 Escalated complaints compared to none last quarter. Of these complaints, one was partially upheld and 2 were not upheld.

24 complaints were handled as a Stage 2 complaints from the start compared to only five in quarter one. This quarter seven were partially upheld and two were not upheld.

78% of Frontline resolution complaints were either upheld or partially upheld compare to 57% last quarter. 78% of stage 2 non escalated complaints were upheld or partially upheld compared to 71% last quarter. Stage 2 escalated complaints had 33% either upheld or partially upheld.

| Frontline Resolution | 11 | |----------------------|----| | Investigation (Escalated from Frontline) | 6 | | Investigation | 24 | 4.12 Closed NHS Complaints Resolved within Timescales

21 complaints were closed within the first quarter regardless of when they were received, and 95% (20) of these were closed within timescales. This is an increase from the previous quarter.

Graph 4 - % of closed NHS complaints closed within timescales

Of the complaints closed this quarter, there has been a substantial increase in those closed with their timeframes.

4.13 Outstanding NHS Complaints

The graph below shows that there has been a decrease in the amount of NHS complaints that are overdue in the past year and with new staff working on the complaints, this could continue into next quarter.

Graph 5 - Snapshot of number of open overdue NHS complaints at a given date The above graph shows that the average length of overdue complaints has decreased back down to a manageable level. This shows the work ongoing to complete the backlog of overdue complaints.

Discussions are still taking place with NHS Tayside to identify how we can improve our complaint response times. However, our plan to trial a more robust and effective complaints system has been put on hold due to the current pandemic.

5.0 INTEGRATION JOINT BOARD COMPLAINTS 5.1 No complaints about the Integration Joint Board have been received.

6.0 POLICY IMPLICATIONS 6.1 This report has been screened for any policy implications in respect of Equality Impact Assessment. There are no major issues.

7.0 RISK ASSESSMENT 7.1 This report has not been subject to a risk assessment as it is provided for information and does not require policy decisions from the PAC.

8.0 CONSULTATIONS 8.1 The Chief Finance Officer and the Clerk were consulted in the preparation of this report.

9.0 BACKGROUND PAPERS 9.1 None. 1.0 PURPOSE OF REPORT

1.1 The purpose of this report is to provide the Performance and Audit Committee with an update report in relation to DHSCP Strategic Risk Register and strategic risk management activities in Dundee Health and Social Care Partnership.

2.0 RECOMMENDATIONS

It is recommended that the Performance and Audit Committee (PAC):

2.1 Notes the work ongoing around risk management across Dundee Health and Social Care Partnership and partner organisations.

2.2 Notes the updated risks around Finance, EU UK Transition and Governance arrangements.

3.0 FINANCIAL IMPLICATIONS

3.1 None.

4.0 MAIN TEXT

Risk Management across DHSCP and partner organisations

4.1 The DHSCP Strategic Risk Register is regularly presented to the NHST Strategic Risk Group, Dundee City Council Strategic Risk Group and Dundee Clinical Care and Professional Governance Group. Horizon scanning is also undertaken by these groups and informs the risk register.

4.2 Following recommendations made in the Risk Management Internal Audit Report in 2018 (Article XI of the minute of the meeting of the Dundee Performance and Audit Committee held on 13 February 2018 refers), work has been undertaken on a number of recommendations. The Tayside Risk Management group, which is made up of risk managers from NHS Tayside, Dundee City Council, Dundee Health and Social Care Partnership, Angus Health and Social Care Partnership and Perth and Kinross Health and Social Care Partnership is working to ensure consistency in risk management across the Health and Social Care Partnerships and their partner bodies.

5.0 Updated Risks around Finance, EU UK Transition, Covid 19 Response and Governance arrangements

5.1 The Financial risks have been updated to reflect the Finance risks have been mitigated in part by the actions completed to date following the Ministerial Strategic Group Self-Evaluation and the completion of actions raised by Audit Scotland. In addition, the enhanced communication channels between the partners and the Integration Joint Board have improved the approach to agreeing financial planning and management matters. 5.2 The EU UK Exit risk was updated to reflect the higher risk in December 2020 when a no deal exit was assessed as likely. However since the EU UK transition deal was signed at the end of December the assessed risk has been re-assessed and reflects the longer term effects of the EU UK Transition.

5.3 The 2nd wave of Covid 19 and rising infection rates and the virulence of new variants of the virus means that the covid 19 response still creates barriers to DHSCP achieving actions within the Strategic and Commissioning Plan. The workforce are also involved in supporting the mass vaccination programme.

5.4 The Governance Arrangements Risk has been updated to reflect the ongoing work to complete the actions on the Governance Implementation Plan.

6.0 POLICY IMPLICATIONS

6.1 This report has been screened for any policy implications in respect of Equality Impact Assessment. There are no major issues.

7.0 RISK ASSESSMENT

7.1 This report has not been subject to a risk assessment as it is provided for information and does not require a policy decision from the PAC.

8.0 CONSULTATIONS

8.1 The Chief Finance Officer and the Clerk were consulted in the preparation of this report.

9.0 BACKGROUND PAPERS

9.1 None.

Dave Berry Chief Finance Officer

DATE: January 2021

### Dundee Health and Social Care Partnership Strategic Risk Register

**Extract from Pentana Risk January 2021**

| Risk Code & Title | Risk Factors | Inherent Risk | Control Measure | Control Description | Residual Risk | Last Modified Date | Date Last Assessed | Latest Note | |-------------------|--------------|---------------|-----------------|--------------------|---------------|-------------------|-------------------|-------------| | HSCR00 Dundee Health and Social Care Partnership High Level Risk Register | | | | | | | | |

| Risk Code & Title | Risk Factors | Inherent Risk | Control Measure | Control Description | Residual Risk | Last Modified Date | Date Last Assessed | Latest Note | |-------------------|--------------|---------------|-----------------|--------------------|---------------|-------------------|-------------------|-------------| | HSCR00a1 Restrictions on Public Sector Funding | Continuing restrictions on public sector funding will impact on Local Authority and NHS budget settlements in the medium term impacting on the ability to provide sufficient funding required to support services delivered by the LB. This could lead to the LB failing to meet its aims within anticipated timescales as set out in its Strategic and Commissioning Plan. | | Budgeting Arrangements | Budget negotiations with the Local Authority and NHS Tayside to ensure a fair and proportionate share of resources | | 12-Jan-2021 | | | | | | | Savings and Transformation Plan | The development of the Transformation Plan and planned savings will mitigate the impact of restrictions on public sector funding | | | | | | | | | MSU and external audit recommendations | Action taken in response to MSU and external audit recommendations | | | | |

Finance risks have been mitigated in part by the actions completed to date following the MSU Self-Evaluation and the completion of actions raised by Audit Scotland. In addition, the enhanced communication channels between the partners and the LB have improved the approach to agreeing financial planning and management matters. | Risk Code & Title | Risk Factors | Inherent Risk | Control Measure | Control Description | Residual Risk | Last Modified Date | Date Last Assessed | Latest Note | |------------------|-------------|---------------|-----------------|--------------------|---------------|-------------------|-------------------|-------------| | HSCRO002 Unable to maintain UJF Spend | UJF is unable to maintain spend within allocated resources which could lead to being unable to deliver on the Strategic & Commissioning Plan | Likelihood | Financial monitoring system | Development of robust financial monitoring systems to highlight key pressure areas and enable action to be taken at an early stage | Impact | 12-Jan-2021 | 31-Dec-2016 | The risks highlighted in the UJF High Level Risk Register in relation to Finance have been mitigated in part by the actions completed to date following the MSU Self-Evaluation and the completion of actions raised by Audit Scotland. In addition, the enhanced communication channels between the partners and the UJF have improved the approach to agreeing financial planning and management matters. | | HSCRO001 Staff Resource | The volume of staff resource required to develop effective integrated arrangements while continuing to undertake existing roles / responsibilities / workload of key individuals may impact on organisational priorities, operational delivery to support delivery of effective integrated services. The DCC recruitment restriction and internal DHSCP vacancy management process is restricting recruitment to posts | Likelihood | Organisational development strategy | Ensure organisational development strategy is agreed, implemented and monitored. | Impact | 21-Jan-2021 | 31-Dec-2016 | Service redesign of in-house Home Care Service and Care Homes is now complete. However the ongoing Covid 19 response means that the staff resource is under pressure. Remobilisation plans have been completed and will be reassessed to mitigate this pressure. | | HSCRO002 Staff Perception of Integration | Negative staff perception of integration due to historical experiences and lack of communication will lead to an adverse effect on engagement / buy-in to new partnership. | Likelihood | Communication | Continued communication disseminated to staff highlighting key issues. | Impact | 11-Aug-2020 | 31-Dec-2016 | Tools such as NHS Inpatients and Council feedback have been developed. However these are separate systems. Managers of integrated teams do not have access to a whole system. The Covid 19 response of DCC and NHST has also impacted on DHSCP workforce. | | Risk Code & Title | Risk Factors | Inherent Risk | Control Measure | Control Description | Residual Risk | Last Modified Date | Date Last Assessed | Latest Note | |------------------|--------------|---------------|-----------------|--------------------|---------------|-------------------|-------------------|-------------| | HSCR0083 Employment Terms | Offering employment terms could expose the partnership to equality claims and impact on staff morale. | Likelihood | Align conditions | Continue to monitor through staff feedback/surveys and align conditions where opportunities present | Likelihood | 27-Jan-2019 | 30-Aug-2016 | Separate terms and conditions remain an issue nationally however locally, all new recruitment is being carried out jointly with the option for many posts to choose which employer to work for. | | HSCP001 Capacity of leadership team | Capacity of management team will be impacted by transition to new Chief Officer retirement. Head of Service, Health and Community Care is also performing duties as Chief Social Work Officer due to retirement of Chief SWO. In addition there is additional work due to a Locality Manager leaving their post. | Likelihood | Sharing of Management team duties | New internal control to be worked on | Likelihood | 21-Jan-2021 | 09-Sep-2019 | Progress is being made to enhance overall capacity within DHSCP. The impact of the response to Covid 19 has also impacted on the capacity of the Senior Management team. | | HSCR0001 Stakeholders not included/consulted | Relevant stakeholders have not been included and adequately consulted with during the development and subsequent implementation of the Strategic & Commissioning Plan which may lead to adverse political and/or reputational impact. | Likelihood | Participation and engagement strategy | Ensure consultation around the development and implementation of the Strategic & Commissioning Plan is as comprehensive as practically possible and compliant with statutory requirements as a minimum. Development of participation and engagement strategy which promotes wide stakeholder consultation and engagement throughout the planning, implementation and review cycle. | Likelihood | 11-Aug-2020 | 31-Dec-2016 | The Participation and Engagement strategy has been published. |

09-Jan-2018 11-Aug-2020 | Risk Code & Title | Risk Factors | Inherent Risk | Control Measure | Control Description | Residual Risk | Last Modified Date | Date Last Assessed | Latest Note | |------------------|-------------|---------------|-----------------|--------------------|---------------|--------------------|-------------------|-------------| | HSCR006c3 | Governance arrangements being established fail to discharge duties | Low | Review of processes established | Implement Governance Action Plan | Low | 31-Dec-2016 | 09-Jan-2018 | Pressure of Covid 19 response mean that work to improve governance arrangements has not been progressed. The Governance Action Plan is implemanted and overdue actions are being prioritised | | | | | | | | 11-Aug-2020 | 05-Jan-2021 | |

| Risk Code & Title | Risk Factors | Inherent Risk | Control Measure | Control Description | Residual Risk | Last Modified Date | Date Last Assessed | Latest Note | |------------------|-------------|---------------|-----------------|--------------------|---------------|--------------------|-------------------|-------------| | HSCR006c4 | Uncertainty around future service delivery models | Low | Strategic vision | High-level strategic vision to be articulated. Clear guidance on service development during interim period | Low | 31-Dec-2016 | 09-Jan-2018 | Communication, participation and engagement with stakeholders | | | | | | | | 11-Aug-2020 | 11-Aug-2020 | | | Risk Code & Title | Risk Factors | Inherent Risk | Control Measure | Control Description | Residual Risk | Last Modified Date | Date Last Assessed | Latest Note | |------------------|--------------|---------------|-----------------|--------------------|---------------|--------------------|--------------------|-------------| | HSCR00c2 Increased Bureaucracy | Revised governance mechanisms between the UB and partners could lead to increased bureaucracy in order to satisfy the arrangements required to be put in place. | Likelihood | Support and roles | Continue to monitor: Ensure clarity of respective roles of the UB, Dundee City Council and NHS Tayside. Ensure appropriate corporate support provided by Dundee City Council and NHS Tayside. | Likelihood | 21-Jan-2021 | 31-Dec-2016 | The Covid 19 response has meant an increase in reporting requirements to the Scottish Government, NHS Tayside and Dundee City Council. | | HSCR00c5 Staff resource is insufficient to address planned performance management improvements in addition to core reporting requirements and business critical work. | Audit Scotland Annual Report 2016/17 - Performance Management Improvements Update (PAC14-2018) | Likelihood | Management plan | Head of Service, Finance and Strategic Planning currently considering identified resource issues.

- Action plan agreed with internal auditor and will be implemented.
- Workplan for existing staff resource is in place and regularly reviewed to ensure appropriate priority given to range of tasks.
- Performance management improvement capacity is on the high level risk register as part of wider support services capacity.
- Through the Tayside Analytical Network joint working with NHS Tayside Business Support Unit is continuing to develop and strengthen.
- Internal Audit report on workforce issues has been completed and identified capacity as an issue | Likelihood | 11-Aug-2020 | 27-Mar-2016 | Proposals for service restructure being developed | | Structure of teams | Proposals for service restructure being developed | 11-Aug-2020 | | Risk Code & Title | Risk Factors | Inherent Risk | Control Measure | Control Description | Residual Risk | Last Modified Date | Date Last Assessed | Latest Note | |------------------|--------------|---------------|-----------------|--------------------|---------------|--------------------|-------------------|-------------| | HSCP0001 Viability of external providers | Financial instability / potential collapse of key providers leading to difficulty in ensuring short / medium term service provision. * Inability to source essential services * Financial expectations of third sector cannot be met * Increased cost of service provision * Additional burden on internal services * Quality of service reduces | Likelihood | Co-ordination to provide services | When required services work together to co-ordinate service provision in the event of lack of provision by external providers. | Likelihood | 11-Aug-2020 | 01-Nov-2019 | Moving from a day by day management of the Covid 19 response to business as usual. Work is going on to develop categorisation of ratings for Service providers including sustainability. | | HSCP0002 Impact of EU Withdrawal | Ongoing uncertainty over Brexit terms with increasing potential for a ‘Hard Brexit’ and lack of knowledge over the associated implications Impact / consequences: - loss of key staff of EU origin - council / partners / others (universities / colleges / businesses) - economic issues due to impact of Brexit on the UK / Scottish economy - loss of funding to medium to long term funding - potential for changes to legislation / regulation - possible issues over procurement arrangements | Likelihood | Scottish Gov EU Transition Information | Scottish Government has planned EU Transition information sessions, and in the event of a no deal EU transition will host daily information sharing and planning meetings to deal with issues as they arise across the country. | Likelihood | 12-Jan-2021 | 21-Nov-2019 | The EU UK agreement signed on the 30 December 2020 means that there will not be disruption caused by a no deal transition. However the long term effects of the EU UK transition will still happen. | | HSCP0003 Impact of Covid 19 | Coronavirus related pressure on resources (financial / workforce) will have a ‘tail’, resulting in ongoing medium / longer term pressure on the HSCP and by association on the council / NHS and patients, service users and carers | Likelihood | Mobilisation and Remobilisation plans | Mobilisation plans developed for the Covid 19 response. Remobilisation plans developed to manage the move to business as usual. | Likelihood | 21-Jan-2021 | 06-Mar-2020 | The 2nd wave of Covid 19 and rising infection rates and the virulence of new variants of the virus means that the covid 19 response still creates barriers to HSCP achieving actions within the Strategic and Commissioning Plan. The workforce are also involved in supporting the mass vaccination programme. |

## PERFORMANCE AND AUDIT COMMITTEE – ATTENDANCES - JANUARY 2020 TO DECEMBER 2020

### COMMITTEE MEMBERS - (\* - DENOTES VOTING MEMBER – APPOINTED FROM INTEGRATION JOINT BOARD)

| Organisation | Member | 11/2^ | 24/3^ | 30/6^ | 22/9 | 24/11 | |--------------|--------|-------|-------|-------|------|-------| | Dundee City Council (Elected Member) | Ken Lynn \*\* | ✓ | | | | | | Dundee City Council (Elected Member) | Helen Wright * | | ✓ | | | | | Dundee City Council (Elected Member) | Roisin Smith | | | | A/S | | | NHS Tayside (Non Executive Member) | Trudy McLeay | | | | | ✓ | | NHS Tayside (Non Executive Member) | Jenny Alexander * | | | | | A | | NHS Tayside (Non Executive Member) | Donald McPherson * | | | | ✓ | ✓ | | Chief Officer | Vicky Irons | ✓ | ✓ | | | | | Chief Finance Officer | Dave Berry | ✓ | ✓ | | | | | NHS Tayside (Registered Medical Practitioner – not providing primary medical services) | James Cotton | ✓ | | | A | | | Dundee City Council (Chief Social Work Officer) | Diane McCulloch | ✓ | ✓ | | | | | NHS Tayside (Staff Partnership Representative) | Raymond Marshall | A | A | | | | | Carers’ Representative | Martyn Sloan | ✓ | ✓ | | | | | Chief Internal Auditor \*\*\* | Tony Gaskin | ✓ | ✓ | | | | | Audit Scotland \*\*\*\* | Anne Marie Machan | ✓ | ✓ | | | |

✓ Attended A Submitted apologies A/S Submitted apologies and was substituted ☐ No longer a member and has been replaced / was not a member at the time

- Denotes Voting Members \*\* Denotes Office Bearer. Periods of appointment are on fixed terms in accordance with legislation. At meeting of the Integration Joint Board held on 30th October, 2018, Ken Lynn was appointed as Chair (the Chair of the Committee cannot also be the Chair of the Integration Joint Board). \*\*\* The Chief Internal Auditor is a member of the Committee and is not a member of the Integration Joint Board. \*\*\*\* Audit Scotland are not formal members of the Committee and are invited to attend at least one meeting of the Committee a year.

(Note: First meeting of the Committee was held on 17th January, 2017).

(Note: Membership are all members of the Integration Joint Board (only exceptions are Chief Internal Auditor and Audit Scotland).#

^ These meetings did not take place.